Month: December 2019

Healing People, Not Patients with Jonathan Weinkle, MD

Jonathan Weinkle, MD, is a general internist and general pediatrician who came to medicine after deciding against careers as a philosopher or a rabbi and is the author of Healing People, Not Patients. He starts off by teaching us how he was able to write a book about his patient interactions without violating HIPAA. His book illustrates the many ways in which it is important to really know our patients as people in order to effectively treat them. The paradox of this is that there never seems to be enough time to do this well, so Dr. Weinkle teaches us how to connect without losing efficiency. While cultural competency is usually discussed, Dr. Weinkle believes that cultural humility really the key – recognizing we don’t know what we don’t know about someone else’s culture. How to keep moving through a visit if you are really listening “with both ears,” but the patient continues to repeat themselves as if you aren’t listening. He also discusses the importance of allowing the patient to set the agenda and then establishing limits to that agenda at the start of the visit.

He practices primary care medicine at the Squirrel Hill Health Center, a Federally Qualified Health Center and certified Patient Centered Medical Home, providing comprehensive care to patients of all ages with and without insurance and representing a broad diversity of languages, faiths, cultures, native lands, and socioeconomic backgrounds.  In addition, Dr. Weinkle serves as a medical advisor to the Closure project of the Jewish Healthcare Foundation (JHF), a project intended to improve the quality of care and change the individual experience at end-of-life.  Under the auspices of the JHF, he is crafting a program to help clinicians master the core competency of respectful communication with patients and families, based largely on the ideas in this book and the research underlying it.  Finally, Dr. Weinkle serves as Clinical Assistant Professor in the Departments of Pediatrics and Family Medicine at his alma mater, and as Medical Director of the Physician Assistant Studies Program at Chatham University.  Driving all of these endeavors is a strong commitment to infusing his interactions with patients with the core values of his Jewish faith, beginning with the idea that both patient and provider are created in the Divine image and must act and be treated accordingly. He can be found at http://healerswholisten.com and @healerswholistn on Twitter.

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Healing People, Not Patients with Jonathan Weinkle, MD

Jonathan Weinkle, MD, is a general internist and general pediatrician who came to medicine after deciding against careers as a philosopher or a rabbi and is the author of Healing People, Not Patients. He starts off by teaching us how he was able to write a book about his patient interactions without violating HIPAA. His book illustrates the many ways in which it is important to really know our patients as people in order to effectively treat them. The paradox of this is that there never seems to be enough time to do this well, so Dr. Weinkle teaches us how to connect without losing efficiency. While cultural competency is usually discussed, Dr. Weinkle believes that cultural humility really the key – recognizing we don’t know what we don’t know about someone else’s culture. How to keep moving through a visit if you are really listening “with both ears,” but the patient continues to repeat themselves as if you aren’t listening. He also discusses the importance of allowing the patient to set the agenda and then establishing limits to that agenda at the start of the visit.

He practices primary care medicine at the Squirrel Hill Health Center, a Federally Qualified Health Center and certified Patient Centered Medical Home, providing comprehensive care to patients of all ages with and without insurance and representing a broad diversity of languages, faiths, cultures, native lands, and socioeconomic backgrounds.  In addition, Dr. Weinkle serves as a medical advisor to the Closure project of the Jewish Healthcare Foundation (JHF), a project intended to improve the quality of care and change the individual experience at end-of-life.  Under the auspices of the JHF, he is crafting a program to help clinicians master the core competency of respectful communication with patients and families, based largely on the ideas in this book and the research underlying it.  Finally, Dr. Weinkle serves as Clinical Assistant Professor in the Departments of Pediatrics and Family Medicine at his alma mater, and as Medical Director of the Physician Assistant Studies Program at Chatham University.  Driving all of these endeavors is a strong commitment to infusing his interactions with patients with the core values of his Jewish faith, beginning with the idea that both patient and provider are created in the Divine image and must act and be treated accordingly. He can be found at http://healerswholisten.com and @healerswholistn on Twitter.

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

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Jonathan Winkle is a general internist and general pediatrician who came to medicine after deciding against careers as a philosopher, or rabbi. And he’s the author of healing people, not patients. He starts off by teaching us how he was able to write a book about his patient interactions without violating HIPAA. His book illustrates the many ways in which it’s important to really know our patients as people in order to effectively treat them. The paradox of this is that we never seem to have enough time to do it well. So Dr. winkel teaches us how to connect without losing efficiency. While cultural competency is usually discussed, Dr. winkel believes that cultural humility is really the key, recognizing we don’t know what we don’t know about someone else’s culture. He teaches how to keep moving through a visit, if you really are listening with both ears as he puts it, but the patient continues to repeat themselves as if we’re not listening at all. He also discusses the importance of allowing the patient to set the agenda and then establishing limits to that agenda. At the start of the visit. He practices primary care at the squirrel Hill Health Center. qualified health center and is a certified Patient Centered Medical Home. It provides comprehensive care to patients of all ages with and without insurance, and represents a broad diversity of languages, faiths, cultures, native lands, and socio economic backgrounds. In addition, Dr. winkel serves as a medical adviser to the closure project of the Jewish Health Foundation, a project intended to improve the quality of care and change the individual experience at the end of life. Under the auspices of the J HF he’s crafting a program to help clinicians master the core competency of respectful communication with patients and families based largely on the idea in this book, and the research underlying it. Finally, Dr. winkel serves as a clinical assistant professor in the Department of Pediatrics and Family Medicine at his alma mater, and as medical director of the physician’s assistant studies program at Chatham University. Driving all of these endeavors is a strong commitment to infusing his interactions with patients. With the core values of his Jewish faith, beginning with the idea that both patient and provider are created in the divine image and must act and be treated accordingly. He can be found at healers who listened calm and at healers who listen, missing the E and listen on Twitter.
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. Jonathan Winkle. Thanks so much for being on the podcast.
You’re welcome. I’m glad to be here.
So let’s start off with your origin story. How did you end up writing This book or even to take a step back, because I know because you wrote about this in your book, how did you end up taking the torturous path to practice medicine?
Sure. So first of all, when I told somebody I had to answer a question about my origin story, they thought I’ve met that how I became a Marvel superhero, but that’s obviously not it. Although a Marvel superhero doctor, that might be fun. So I like to talk about it. This is my, my failed Rabbi story. I had kind of a notion that I was going to be you know, a congregational rabbi, I was really interested in pulpit and in the learning and sort of inspiring people with that kind of religious teaching. And believe it or not, I got multiple, multiple adults who I was close with, gave me feedback that this is no kind of a job for a nice Jewish boy. You know what the irony of that’s thinking for a minute. And, you know, one of them was orthopedic surgeon who was very close to our family. That was my father in law. He’s a psychiatrist, really sort of pushing me in the direction of medicine and say, Under this, this is really where you want to be. I talk in the book a little bit about how, especially in American Jewish culture, being a doctor is put up on this kind of pedestal of, you know, not only in American society where you can, like, you know, get out of speeding tickets and, you know, get your whole separate room in the cafeteria in the hospital and keep people waiting for hours where you blow in and out for five minutes. And they think you’ve done them a favor, like there is something kind of sort of glow around medicine and around being a doctor that is particularly reinforced in Judaism, like, just for the for the background of everybody’s audience. For a long time when when things were very traditional and insular doctors were like the one group of people who were allowed to like study secular science and read secular books and get an education outside the village because it was considered so important. And turns out that in my family as well, being a doctor carried more cachet than being in than being a rabbi, so I did and ultimately decide not so much because they pushed me to but because I was living in a place where Like, you know, we actually don’t need more clergy, we need more people who are doing other stuff. And I started to feel the pull towards medicine, like I wanted to be around people. I was starting to enjoy science more than I had in high school. I think the difference is sort of being exposed to it as an adult and saying, Hey, this is actually cool. My 10th grade chemistry teacher didn’t make it cool. But this is cool.
Could you could you clarify where you were living at the time because I grew up on Long Island, where there was no need for more Jewish doctors, myself, good doctor as well. I didn’t really get a place where someone would turn around and go, you know, Long Island needs more Jewish doctors
right now. So that’s good to clarify. And so when I when I came to the decision to go into medicine, I was living in Israel. So especially if you’re not orthodox, but still observant in Israel, that conservative Jewish community there is tiny, we did not need more rabbis, because most of the Jews who are are in that community in Israel, our American rabbis who have moved to Israel, so they didn’t need another Rabbi and in Conservative community in the States. We don’t need more rabbis. We need more people who are lay people doing, doing other things, but participating in a community and knowing that so it wasn’t the dive in or somehow a dearth of doctors, although we’re getting to a point where there there is going to be in both countries, just as as the, you know, the workforce ages and people are not as excited about going into medicine, which I will talk about in a little bit as to why there’s a there there is definitely a pull for me in that direction. But I saw I was living in Israel at the time. I now live in Pittsburgh, which is definitely a heavily medicalized community. But what I do, there is definitely a lack primary care is chronically in shortage. And there’s room for more of us for sure. To provide that first point of contact and to really be able to get to know people. That’s what I want to do now in terms of where I got to the book and why you know why I’m practicing the kind of medicine I do. You know, I went to I went to Medical University Pittsburgh, institution, but had just gone over to a curriculum that is entirely based on organ systems. And I was struck by on the one hand, we had these great problem based learning cases where from the very first week we were meeting real life, people who had medical issues, and they were talking to us about not only their issues, but also their lives. I mean, first thing that’s going on a six year old girl with cystic fibrosis, and she talked us about what it was like to have CDs. And later in the week, we met a woman who was not quite 70, who was already a great grandmother, but who was like, you should look like she’s about 50. And like, had all this energy and was talking about what it was like to be an older African American person living in an inner city neighborhood in Pittsburgh and what challenges that presented for her, we got whole person care from the beginning and then we turned around and went into the anatomy lab and started dissecting the cadaver and started getting taught about anatomy and physiology and pathophysiology organ system by organ system and totally broke down that model into part like seemingly unrelated parts and at some point is like Which organ system does the mouse belong to? like is that gi is that respiratory like, you know, and things actually do get overlooked because they don’t quite sit that neat in system fragmentation. And it was pretty quickly that, you know, that really lovely human face that they put on that isn’t it right at the beginning totally disappears. And it stays that way. Like you do problem based assessments in summarization, but in others, you’re doing an organ system assessment, like when you’re in the ICU, right? It’s, it’s this crazy thing. The story I tell in the book is a friend of mine was on it was on a CCU rotation. And he actually started mentioning and so in the spiked a fever this morning, there was this infection and Doctor holds up his hand, he’s like, hold on, draw this little box around his heart on his chest, and waves off. The whole discussion is like, if it isn’t the heart, I don’t want to discuss it. So that fragmentation really bothered me because I had chosen medicine over lab science or whatever to be around people and to be getting to know people and helping them rather than solving like technical problem. The other thing that really influenced me and this is where the whole I, you know, I remember I wanted to be a rabbi at one point thing came in. I spent the summer between freshmen and freshmen. Sophomore year was my first and second year of med school, rounding with the hospital chaplains. And one of them gave me this book by a longtime chaplain named Joseph Bowser. offski, who is was in Minneapolis for a while and is now in, in the Chicago area is called to walk in God’s ways. And he talks about sort of the theory behind visiting the sick and how, when you visit somebody who’s sick, there’s actually a strong belief not just in Judaism in a lot of religions that the visit itself can actually heal some of that person’s suffering takes away 160 as part of the suffering because I’m still trying to be very exact about it. And I thought, you know, if nothing else, when I’m seeing a patient, I should have they should walk away from me feeling a little bit better than they did when we met. Even if I haven’t done anything. prescribed medicine, ordered a test. injected them with something like I want them to feel better just for the interaction between us, I want it to be like a visit, not just like a doctor’s appointment. And so those two things really informed me and put me on the path that I’m on now was was of trying to make a relationship out of things in a relationship that in and of itself is healing. But there’s a lot of stuff you have to do in that relationship in order for it to work that way.
So how do you dovetail that into the into the book, right? Because your book is all about those relationships, right? It’s all about knowing knowing the patient well enough that you can kind of read between the lines to figure out what their complaint is. Sometimes I’ve heard that referred to as the question behind the question, right? The patient asked you a question. But what they’re really asking is something quite different. But if you don’t know the patient well enough, or haven’t talked to them in depth enough, it’s hard to pick up on that. So So how do you how do you dovetail that into into the book? How’d you get there?
Yeah, that’s Actually a great way of, of describing it as the question behind the question. So, you know, you go through you go through med school, you go through residency, and you get a lot of sort of scripted ways of responding to things. Like there’s the there’s the chest pain, decision tree. And there’s the, you know, there’s the The other thing you know, we’ve there’s like all these books of different algorithms that you can follow and kind of lists of questions that you learn to memorize to ask people and get the answers that you’re looking for. But the answers that you’re looking for may not be the ones that the person is trying to give. So, I was just sort of ramping up this probably a year or two after I started practice. And I went in to see a guy who said, Listen, I have an abscess that I need you to drain. And he pointed to his foot and he had a huge abscess on his on his foot that he tried to drain that he wanted drained. And I looked at it and I was like, great, there’s no surrounding cellulitis. It’s huge. I don’t have to worry that I’m going to hit something underneath. I have the tools I have the stuff I asked him a few more questions about new systems. Mix symptoms and various other things and went ahead and got my supplies beta, dine them up, made a nice clean incision got all kinds of junk out of there. I guess I’m on a podcast that other doctors listened to create a huge amount of pus out of there, got it cleaned out bandaged, packed, looked great. Send him on his way. Three weeks later, he comes back and he says, Listen, I really appreciate the work that you did, my foot feels much better. I could put my shoes on all as well. Now I want to talk to you about my heroin injection problem, which was the question behind the question all along. I hadn’t met the guy before, didn’t have the relationship and honestly was a little bit naive. You know, as much as I worked in a city hospital, the hospitals that I was training in didn’t have quite the injection drug population issue at the time in the early 2000s. That certainly most hospitals have today and that other inner city hospitals had kind of on a more regular basis. If I had been elsewhere in Pittsburgh, I probably would have seen more of that at that time, too. But I missed it, both in his demeanor didn’t suggest anything about drug problem. I wasn’t looking for it. And I was seeing it very much as a, I have this problem. I want it fixed. I have 15 minutes, I’m going to fix the problem. And what he really needed was the relationship to being able to unload that. Because you know, certainly even if you ask the question, sometimes the first time, you don’t get the answer you’re looking for Anyway, you inject drugs, I don’t know, I don’t inject drugs. Possibly there was this idea that because I didn’t immediately be like, Oh, he’s an injection drug user and convey some kind of stigma that maybe things worked out a little bit better because he felt like I was treating him like everybody else. And so the next time he could ask me about the drug problem,
is the fact that you hadn’t been judgmental because of your negativity you hadn’t been judgmental. And so that led him to be more comfortable and actually come out with And ask you then be forthright about his. his, his issue is concerned.
Yeah. And that’s that last part only occurred to me now but I’m gonna stick with that story. But yeah, for sure for sure. I mean, the non judgmental thing is so huge. I there’s a whole chapter in the book about stigma. And there’s sort of different things that we stigmatize they’re things that get stigmatized because they are sort of considered lower Echelon in society, whether that’s single parenting or injection drug use, or a variety of other things that people automatically get judged for the minute they walk in the door. And I know because I’ve heard my own patients tell me the story of how they’ve been treated. One person told me one time that they had been in the emergency room because they had pneumonia. There was a mention on their chart of a history of prescription drug abuse, which was true, going back seven or eight years prior. They had not been abusing drugs at that point for about six or seven years. This wasn’t a visit about you know acute exacerbation of chronic pain or anything that would have suggested they were drug seeking. And I shy away from using that term but that was that was how this was kind of played out in the ER that day. And they were trying to get somebody’s attention because they’re having trouble breathing and wanted some oxygen and couldn’t get the time of day because they got kind of put in the corner room and ignored because of that history. So, you know, whether the stigma is coming from that the stigma that people get put on them because their quote, self inflicted diseases related to smoking or alcohol use or obesity or lack of exercise or whatever. But as I I went in, when I was writing the book, I looked up the top 10 causes of morbidity and mortality in the US and in the world. I think it was a who graphic from sometime like 2015 2016 and most of the leading causes of death in the world at this point are quote, self inflicted, but one that wasn’t a chronic disease is road traffic accidents as my my British Empire colleagues like to put it You know, they so I mean, you could blame that on the on the injured person as well, right? They were driving too fast or they were under the influence. So everything we do in a sense is somewhat self inflicted. When you find me the physician that hasn’t self inflicted a wound on themselves. Come Come let me know,
where their patients because we all know how common medical errors are, right most end up in any type of an injury. But But still, you know, we’re to write that paper To err is human. Exactly. So you ended up writing the book, and to kind of help shed light on why that is, those interactions are so important and how important it is to establish that rapport so you can get to the question behind the question. So. So would you tell us you don’t you you already gave us one of one of your favorite stories? Give us a couple of others. And then my question, my follow up question is going to be how do you do that without Have a violation because it seems like you’re giving giving some details away yet you’ve published a book so I would imagine you’ve consulted lawyers and your your you you went the Jewish doctor wrote not the Jewish lawyer route, so you are not alone. That’s right. You have some insight into into that because you didn’t include some stuff in your book. So first give us give us a one or two more of your favorite stories and then we’ll
Yeah, and we are we’re heavily trafficking in stereotypes today, but what are you gonna do? So, so the story I was gonna tell second anyway is actually a great way to illustrate how I did this legally. So my co is a lawyer and I have to give a shout out to my to my to my co somebody who’s been very involved in social justice both in the general community and the Jewish community really like we I’m in a federally qualified health center really keeps us on mission and created this culture of, you know, we are here to serve people not you know, Do high volume or efficiency or whatever I mean, yes, we want you we want we want efficiency, but we’re here to serve people. In that vein, you said something really important to me, which is when you’re telling stories, whose story is it for you to tell? Who does it belong to? It belongs to the patient. Right? So if I’m telling a story, and actually, I’m Emily Silverman, who’s the doc from UCSF who runs the Nocturne us podcast and live shows, she also says, like, when you’re out there telling a story about something that happened to you, and medicine, it needs to be your story. Right? So not, this isn’t this crazy thing that happened to one of my patients, but this is this crazy thing that I realized in the course of taking care of this patient, right? How did it change you as a person? How did it affect you as as a, as a doctor, as a human being, as a parent, whatever it was, that’s your story to tell. The simple fact that that other person’s story that’s not really your story to tell. So First of all I had to get permission from from the CEO. This book went nowhere before she had read it in its entirety and told me that she, you know, she loved that felt like it was something that should be out there. Some of the writers that do this, go out and get permission and explicitly get somebody to sign off on that. And listen, that’s something that I could have done. what I ended up doing, I’ll illustrate with it with this next story. So and full disclosure, this this happened before I had a son who had severe scoliosis and had to have surgery. But for whatever reason, I had about three or four people in the space of six or eight months come in as new patients who among their medical problems had untreated scoliosis, from childhood and they were all in there, anywhere from their 30s to their mid 60s. And each one of them it was a significant part of our interaction, save for the last one, which I’ll get to, but for totally different reasons. So first person, the scoliosis came up right away because I walked in and we sat down and I And I said so. And anyway, I noticed, you know, based on your age, you can be 65, and a couple years and personal 70 like 65. I’m 53. And it turned out that the birthday had been entered in the computer wrong. So it was it was purely like an administrative error. But what she said is, look, you know, I’ve had the scoliosis for a long time, and in her case was caifa scoliosis. She was pretty badly hunched over, she’s like, people mistake me for being much older all the time. And I’m not old, and pretty feisty. And so it became this running joke between us like, you still think I’m an old lady. And it was something that had just become a characteristic of her appearance and it was actually affecting her breathing pretty badly because she had COPD on top of that. So having a ribcage that wasn’t shaped normally made kind of hard for her to breathe, but it wasn’t so much that as it was just the way it affected how other people perceived her. That was the first one. second one was a person that I took care of who had develop such chronic pain based on that, that every time I would walk in the room, if I had, if she had been sitting there for long enough would would actually be kind of either rubbing herself or actually banging herself against the wall. It was one of those old things about the if your head hurts banging against the wall because it’ll feel really good when you stop. That’s more or less what she was doing. And this whole perception that she had herself of just being completely incapacitated by by the curvature, which was definitely very visible, but she had kind of lost her sense of being able to care for herself and unfortunately was, you know, was far enough into her midlife that there wasn’t really anybody who was going to do any kind of correction, there wasn’t any if they did, it wouldn’t have relieved the pain. So there was this really sort of tragic sense about her and to relieve that by just kind of self abusing a third person transferred in from another physician. Again, chronic pain but sort of much more articulate about what she was feeling and how she dealt with it. And was sort of early 2000 teens. And so it was just as things were starting to get a lot more difficult to get chronic pain medication prescribed, as people started to kind of crack down a little bit, and we were starting to transfer people out of our practice not too long after that, and the scoliosis and the pain that resulted from it sort of became the next this big battle back and question of, you know, how much do you how much stigma somebody is putting up with? How much does How much do you believe something at face value versus challenging? And if you challenge Are you stigmatizing that person further and labeling them, and it was all around, you know, I’ve suffered so much because of this. And, you know, all of my other doctors have treated me horribly, and you’re the first person that’s listened to me. I think, based on what I was able to glean from other notes, probably all of which was true, but it became a real sticking point. Then I get to the next person, so 20 something woman we take care of a lot of new refugees In my practice, and this was at a time when we had a huge just constant flow of people, particularly from, from certain countries from Bhutan, from Iraq from, from Burma, excuse me, Myanmar, and I walk in the room, and I see something’s a little bit off, and I get the physical exam and I go, I go to listen to her lungs, and like, Wow, she’s got a really huge bulge on the right side, like she’s clearly got scoliosis I ever stand up, I do the Adam’s test. And I’m like, So how long have you had the scoliosis is has been there since you were a teenager? And she says, What scoliosis with the translator explaining to us like, you know, the curve and your spine is like what? curving my spine? I don’t have a curve in my spine. Your back hurt. No, my back feels fine. Are you okay, doctor?
And so, you got to see through this, the context of what that illness means to each person. And in order to do that, you gotta you got to spend some time with somebody and recognize like, it’s not just a diagnosis on paper. It’s not just a anatomy or Physiology or pattern. physiology, you know, hormone imbalance, whatever. It’s not just the meds you prescribe. There’s a whole life story that’s built around that whether it’s nobody will give me the medicine that I need or whether it’s I have to throw myself against the wall to feel better or whether it’s everybody thinks I’m a little old lady or whether it’s there is no story here. I don’t know what you’re talking about. Now, I said this was to illustrate how I tell these stories legally. In the book, you’ll see that I give each of these people names. I give each of these people a background, whatever, or at least through the name imply that somebody is African American or Latino or wherever there are. So Kim Manning, who is a med pedes doc at Emory University, she says she writes the blog tales of a greedy doctor and as on on Twitter under a handle that has something to do with Grady doctor. I can’t remember it off the top of my head, but she’s fantastic. One of her first blog posts is about the 18 unique identifiers. And she gets that number from research ethics where you know when you’re D identifying charts, there are sort of 18 details he has to strike and see Look, in my, in my storytelling, there’s one detail that everybody knows, which is where the story takes place because I work at Grady in Atlanta, everybody knows that that’s where it happens. But I change pretty much everything else, unless I have permission from the patient not to. And so a lot of my stories are composite stories. The essence of the story is the same. Right? The the link, for example, from an abscess to a heroin addiction, but some other amount of the details. I never say which ones are altered? Because obviously if I said which one is that we’ll flip it around and give me the opposite one. If I if I said, well, the gender is changed, that makes it pretty narrow spectrum of things that it could be instead by changing a few of the details or merging things together, and sometimes it’s the diagnosis because the diagnosis isn’t what matters. Sometimes it’s something else. I save the kernel of the story that’s the hundred percent true part and couch it in sort of somebody else’s things or or I make it so general that it doesn’t make a difference. The CEO that I was making Before who gave me the, you know, the whose story is that to tell idea. One of the things she said was, let’s do a story at one of our board meetings or one of our fundraising events or whatever. And she’ll often ask my chief medical officer or one of the other providers, like, give me a few stories. And then she will obfuscate details in the way that I do, saving the kernel of the story that matters, but changing enough of the details that they’re not identifiable. And my chief medical officer once said to me, You know, I was at I was at a meeting where she was telling a story, and it turned out afterwards it was my patient, and I had given her the story, and I didn’t recognize the story she was telling, because she had done such a good job of of making it anonymous or making it about somebody else. So so you’ll take a patient story, and then if the patient reads it, they’ll go, Hey, this sounds like me, and then there’ll be some details in there that will contradict that though that, but wait a second. I’m not from butanna. He says that the patient here It just wasn’t a refugee from Exactly. Exactly. So don’t make don’t have a flash of recognition of I feel like this, like this is this resonates with me but not me. This is me there are a couple of situations where after the fact I looked at and went, yeah, nobody else will recognize this but the thing that I had to keep the same, they’re gonna remember saying that line to like, sometimes it’s a quotation I don’t remember saying that to me. So I’ve gone back to them after the fact and said, Listen, nobody else will know this was you because you said that line to me in confidence behind closed doors, but you’ll know it’s you. Is it okay that this is in there and nobody that I did that with said, Now you got to pull that story out of book. They’re like, Oh, great. I’m glad it’s helping people. I think because they felt like it wasn’t going to expose them to the world. And I’m really careful. You know, it’s just like I am in person. I’m really careful in the book and everything I write not to write about people in a disparaging or judgmental way, which includes Yeah, I heard your your most recent episode about dogs on social media and and sort of my hearing what you say out and that in that forum and, you know, I’m the same way with that I’m the same way with my writing. I try really, you know, other than the rant that I posted about orbits yesterday. I have no doctor patient relationship with orbits. So they Um, I think they appreciate that I’ve taken such an interest in their story, and that other people are going to learn from and benefit from it, and that they’re still going to be anonymous to everybody but me and then
I think that’s,
that’s going to be helpful to a lot of us that that one of us use our interactions and use our because we all have so many stories to tell, and so many interesting stories to tell. So there’s so many things that inform on human nature on what we do. And I think most of us are afraid to come out with these stories. So I think that’s the 18 unique identifiers. That’s very helpful. And then yeah, blending, blending patients blending their stories together so that the no person can really identify That’s definitely them. I think that’s, that’s extremely helpful. So So, you know, you talk about how important it is to really get their backstory so you can frame the discussion and figure out what it is, what what’s the help that they’re looking for and how you can help them. Yeah, the problem is, how do we do that? efficiently, right, like so if I, if I really take my time with, with my patients, as much as I’d like to have, and as much as they’d like to have, you know, I really enjoy those interactions the most. Yet, if I have a cancellation or something, I can just sit back and take my time and schmooze a bit. But in reality, either what’s going to happen is my waiting room is going to start to fill up and ultimately I’m not respecting the time of those in the waiting room. Or if I make my appointments longer for some of it’s, it’s an issue of bottom line, right? It’s going to affect our income significantly. For others. If they expand their appointments, it’s going to lead it’s going to bleed into family time so then you don’t get to see your family and and for others if you make the appointments longer. decreases access to care. So you might want while you might be respecting the person that’s sitting in front of you, you’re not respecting the person in the waiting room and you’re not respecting the person who can’t make an appointment for a couple of weeks. Because, because the appointment times are so long that there’s just no availability. So how do we, how do we get past that? How do we be respectful of the person in front of us and and get to know them and be respectful of the person in the waiting room?
Sure. That’s a great question. I mean, I mentioned during the prep time I get that question every single time I appear as a guest speaker someplace. Every time I’m discussing this book with a colleague, they’re like, well, so you know, that’s great. How do I fit this into my schedule? Time, pressure is huge. You know, I spend one whole chapter the book sort of discussing systemic reasons why we don’t behave in this way, why we don’t practice the kind of listening that I that I espouse why we don’t necessarily speak in the terms and address people in ways that are as respectful as they could be, and so forth. It is really hard. And then I think the third reason that you gave for where I work is the most, the most critical, you know, we are a, in a lot of ways a provider of last resort for people. And if we don’t have room, they got nowhere else to go. And so having those longer visits does it does really limit access for other people. And what are we going to do instead? So I will, I will put a disclaimer out there right away. I’m not that fast, right. So I fall behind schedule. I will I will readily admit that but I don’t fall nearly as far behind schedule, as I think a lot of people would expect. I went to my own tcps office about 1112 years ago with my grandfather who saw a different doc in that same office and his Doc, so that office had a sign out front and I would say how far behind each doctor was running. My guy, by the way, was the only one who wasn’t behind at all and as I learned is never behind and I haven’t figured out how he does it. But my grandfather’s doctor was 45 minutes or an hour being And I think people here that may expect that I’m always at least that far behind. And maybe by the very end of the day, I will be there. But yeah, it’s actually easier than, than I would think much of the time. And there’s a few a few things that have helped me a lot. One is going to talk a lot about my experiences with working with people that are from other cultures and from other backgrounds and trying to figure a lot of stuff out. And there’s so much talk in the in the community right now about cultural competency. And the pushback against cultural competency also is how am I supposed to know all this? And how am I supposed to provide culturally competent care when I’m in so much of a hurry? And I think the flaw is that we talk about competency instead of cultural humility, which is cultural humility is just assume right from the get go, that you don’t know everything, and that there’s some stuff that’s so far beyond your knowledge that you don’t even realize you don’t know it. And so you can cut out all of the stumbling and missteps and just say there anything I need to know? And sort of get right to that basis. Now the problem, of course, is that the patient somehow sometimes is not culturally humble enough to realize that there would be any way that you wouldn’t know, well, obviously, but with a Muslim patient, it wouldn’t even occur to them, maybe if they’re just arrived in the US to not know that the doctor doesn’t realize that Muslims fast during the day Don’t during Ramadan. And so if you ask them, is there anything I should know? And they think, well, of course, I fast during Ramadan, but everybody knows that, then there’s this gap. So sometimes it does take a lot to figure that out. But cultural humility, you assume that there’s going to be things that you’re going to miss. It makes you sort of more willing to reset when you miss something, and it also makes you more willing to ask right upfront, I think I’m missing something. So let’s you know, instead of us having this dance around where we say things that don’t actually make any sense. Let me ask you the question. The other thing is, I often will look at the falling behind and things You know, with some of my patients, I’m on a third or a fourth visit, about the exact same problem I can literally like cut and paste the the HPI of my note because I know what they’ve what they said. And it’s because there you go,
it’s a great way to save time, save
the turmoil and save time. But what why it’s happening is because I will realize belatedly that I didn’t take enough time the first or the second or the third time to check understanding to do a teach back to make sure that they understood, and they ended up not taking the medicine correctly, not taking up the medicine at all not getting the diagnostic tests, and they present with the exact same symptoms. For the third time in 12 months. I haven’t saved any time. I might have saved time at that first visit, which helped the patient immediately after them, but I haven’t helped them very much. Now I’ve used up three more visits that could have been taken by somebody else because maybe I would have seen them in a year instead of seeing them every three months. Because they’ve needed multiple visits for the same complaint with the exact same status, I haven’t gotten worse, they haven’t gotten better. But we didn’t fix the problem because we didn’t take the time to make sure it was fixed. The, the classic example of that is you send somebody who’s from a more traditional culture where there’s not a lot of modern medical care available to get physical therapy. They come back two months later, how’s your shoulder still really hurts? It’s not any better. The physical therapy didn’t help. Well, how did you do finished physical therapy, I went once and it hurts so much that I never went back. Right? So even if I take the additional two minutes to be like, Listen, you’re going to go to physical therapy and your frozen shoulder and the first time they try and move it beyond your current range of motion, it’s going to hurt like hell. And so it’s the second time and eventually as you do those exercises, and by the way, they’re going to give you homework and you’re going to have to do that at home every day. If they go in with the expectation that the doctor is going to touch them, the therapist going to touch them, they’re going to magically Feel better than when they go in, they’re not going to feel better. And so now I’ve got to have a, an additional follow up is because I’ve got to send them back to PT with adjusted expectations, and they’ve got to come back again. So that’s, that’s a big thing is sort of thinking of it as an investment in eventually being more efficient. But maybe today, I’m not gonna be so efficient.
You have some patients who end up repeating the same things over and over during the same visit. Right? And because they feel like you’re just not hearing them, you’re just not understanding them. So, you know, to do active listening. in that setting, it would actually end up saving time, right? Because that’ll shorten the visit. Do you have any advice for that situation where the patient just, you’re doing your best to listen, you’re doing your best to understand you’re trying to maybe even repeat back what they’ve said, maybe rephrase it, and they’re just, they’re just perseverating and and you You’ve reached kind of a sticking point. Do you have any advice in that situation for how to let them know that you do understand you are listening?
Yeah, so there’s sort of three things. One is the active listening. So like sort of reflecting back what they’ve said so far, and maybe reflecting it back with some, with some emotional data in there, like, so you told me about this shoulder pain that you know, you move it even a little bit too far, and it really hurts you. That must be awful, to not be able to use your arm the way you need to, let me help you with that. Right. So you’ve now if they’ve if they’ve been repeating that, since we’re on the shoulder, I’ll stick with the shoulder repeating that two or three times you’ve given them very clear evidence to use and you directed the conversation like okay, we’re going to move into what are we going to do about this? So reflective listening, like you just mentioned is one really great strategy for that and it does save some time sometimes because I think we have if we’re trying to be you know, good, not interrupt the patient, whatever, and you leave too much space. There’s dead air, somebody that we have a natural tendency to want to fill that dead air. Like when you ask a question in a lecture, and like most lectures, including me up until a couple of years ago, if you would you ask a question and it’s not answered within like three seconds, you just answer your own question because you can’t stand the silence. Turns out, he’s supposed to wait about 30 seconds. patients feel the same thing. Silence is awkward. So if doctor doesn’t answer them right away, they’re just gonna keep talking if they have nothing else to say. They’ll repeat themselves.
You actually mentioned something there that that was mentioned on a previous interview of mine by a dentist, actually, she’s okay and calls herself the inspired dentist and talks about emotional intelligence. And, and one of the big takeaways from that interview was when the patient comes in, they have their complaint. What you should do is acknowledge that complaint. So like, exactly what you said, I can’t move my shoulder. It’s really Wow, that sounds really uncomfortable. It takes an extra five seconds, but just saying that And I’ve tried to incorporate that into a lot more of my visits since doing that. And so it just takes seconds to do and it ends up being so powerful.
Yeah, one of the things that I did in my, one of my visits today is you don’t even have to wait for them to say anything. I walked in the room, and I said, Wow, you look really sleepy. There’s something is something wrong, have you not been sleeping well at night, and you just look she was kind of holding her head and her eyes were closing and she looked like she was going to like conk out in the chair. And it actually turned out that she’d been having sort of chronic migraines that flare up every winter. And I was seeing her kind of shielding her eyes against the light in my very brightly fluorescently lit room and not wanting to open them all the way. So even acknowledging data that hasn’t been explicitly presented to you, but that you pick up got us right on that track to talking about what was really bothering her which was our headache from before that I said,
I didn’t say that to me sometimes too because I have three little kids. You look really tired and I’m not the patient, so I really don’t appreciate that. I might look that tired. But, but I I don’t appreciate that. So sorry. Sorry.
No, that’s okay. I mean, I know from from our conversations earlier in the fall that you’re you’re still in baby boot camp territory with with the third one. So yes.
My, you’ll be leaving Parris Island shortly. Yeah. Your oldest is held,
my oldest of three is currently three and a half. So we’re all they’re all. They’re all squeezed together pretty tightly
in for a penny in for a pound Good work.
So some of the other things that can be done in that same situation besides acknowledging, if somebody repeated something three or four times that’s one of those clues, like you don’t even know what you don’t know. They mean something else. This is where the question behind the question comes in. So after the second or third iteration of the exact same complaints, especially if you’ve already done the explicit acknowledgment and sort of emotive resonance, that’s where you go think that this means something more to you than I then I realized what’s what is so bothersome to you about this particular symptom or what what effect is this having on you that it’s so important that you that you’ve needed to tell me this four times? Clearly I’m missing something right now, that’s always I language, you’re not saying something wrong, or you’re not leaving out details. I’m not getting something, can you please explain it to me so that I understand better? Right. So it’s the doctor is, is getting this. This is the humility rather than competency, right? We we love to be competent at things we need to be more humble about things. The thing that we need to be most humble about is we don’t always understand what’s being told to us immediately or if we think we do, we may be misunderstanding. And I guess the third thing is kind of getting into more of the two big techniques that I’ve been working on lately, aside from the one that you mentioned right at the beginning of this series of questions, which is use the no shows and cancellations to expand the visit before them and just like you to breathe a sigh of relief that you can talk for longer. I cheat like that all the time. Like if somebody’s not coming in, okay, well, let’s just let’s talk about your grandkids. Let’s talk about the other things that we need to do. But techniques that I’ve really worked on a lot explicitly. One is agenda setting. And there’s actually some really good research that out there. I’m not a researcher, but I love to make good use of other people’s research. So I went to a conference that was run by the Lown Institute, about two years ago. And we all know the classic study about doctors interrupting patients and average of 18 seconds into their chief complaint, right? It turns out that studies actually been replicated at least four times over the last 20 years. And they get different numbers. But they’re pretty consistent here. The shortest one I think, was 11 seconds, and the longest was 23 seconds. So that’s one. Number two, when they did actually get providers to back off, whether it’s doctors or pa or nurse practitioners to back off and not interrupt. Most patients stop talking after two minutes, when they’re asked their chief complaint and the provider says absolutely nothing to interrupt them. They finish in two minutes. So that’s not that long for somebody to set the agenda for the entire visit. And then because what you can do afterwards, and I know lots of people do this, my partner who is a couple of years long, it’s a couple of years senior to me in terms of when she graduated med school and how long she was in the job. Before I came on board. She always taught me you know, her rule about what are we going to talk about today, you pick two, I pick one. And so she would say we’re gonna we’re gonna have a three item agenda, you get to set two thirds of it, and I get to set the last piece. If you give them two minutes to talk and tell you everything that’s on their mind. You use the sentence that we’re all taught. Wow, that sounds like a lot of things going on. And whether the whether the excuse and it’s not really an excuse, I mean, this is legitimate, right? None of us can focus on eight different problems to any degree of efficacy in a single visit. Or even four like three is probably about the cognitive limit before we start to forget things before we start to make mistakes. So if you let somebody talk for two minutes, and they give you their whole agenda items, like, that’s a lot of stuff.
I’ve written it all down. I don’t think we’re gonna do you any favors by trying to involve this today, what are the two most important things on that list? That’s one way of doing it. When you set the agenda explicitly with somebody versus when you don’t, if you enter, when they interview interview people after the visit is over. An explicitly set agenda you get about 80 plus percent concordance between the physician and the patient about whether they think it was a useful visit, whether whether things were done to the patient satisfaction, versus only about 50% of the agenda is not set. And the data on whether or not it is said is that in at least about 30% of visits, it’s not being said at all. So there’s a similar study that looked at whether or not people are actually coming up with a shared plans, shared goals at the beginning of the visit. And if we’re talking about my idea that you know People are you’re serving human beings you’re not treating patients you’re you’re serving a person. You know whether it’s the the Jewish or Christian idea of people being created in God’s image, whether it’s the Hindu idea of nama stay, which is the God within the salutes the God within you, or a non religious idea, like the humanism and medicine society that talks about human beings has infinitely valuable ends unto themselves. One of the best ways that you can tell somebody, you are human, and I am treating you as human is what’s going on your goals matter to me, and I am going to take your goals and make them my goals. I want to do these things with you. So setting that agenda, which like I said, only takes between two and four minutes at the beginning of the visit can make a huge difference. The other thing, and this sort of develops from agenda so I mentioned during the, the prep time I’m talking, my friend Zack Berger, who’s a doctor Johns Hopkins works in one of their Spanish language clinics and does a lot of things. He’s actually also Got a book out. That’s like the mirror image of my book. It’s a book for patients called How to Talk to your doctor.
And he and I have been talking about. So if we’re going to practice this kind of really relationship based care in an environment that wants us to see somebody every 15 minutes, we’d love to change that parameter. So we had more time. But until that happens, what are we going to do? And we’re developing this list of sort of archetypal questions to maximize time and one of them that I came up with was, you get in it, you get an agenda, and maybe setting the agenda isn’t they give you their whole laundry list, but we don’t have a lot of time. And I know, you want this to be valuable to you. What’s the one thing that is critical for us to talk about today, so that you walk out of here feeling heard, even if it’s not a medical issue, right, because a lot of his patients, a lot of my patients, their worry is they’re not gonna be able to pay rent next month. They’re not going to be able to find childcare for their kids together. To the chemotherapy that their oncologist has just prescribed for them, and, you know, they’re gonna have to decide between their kids being abandoned and see what is being called, or them not getting treatment for their cancer, you know. So these are, these are the things that come up and sometimes, you know, giving them their flu shot is not really anywhere near the top of the priority, not that I disparage flu shots, I’m totally in favor of flu shots, please get your flu shot. But that’s, that’s really what matters to them. So that’s one question that we’ve come up with. You know, one of the other questions is who’s your village? Right? We spend so much time on care coordination in my in my practice, and I spend a lot of time during my visits on care coordination. If I start asking and I have begun doing this, since it occurred to me that that was a really important thing, who are your people who’s your village who supports you? And that’s easily accessible on a sticky note on the chart, then I don’t have to ask all of the questions and have an answer tomorrow. I can’t do that because I don’t have a right well, why don’t you have your drilling down to this thing? If you start from Who are you People whose your support system and what do they do for you? You know, I, I put it in particularly religious terms, if you want to read it really read about that you can go to my website and read the blog that I wrote about it. But it’s called cutting ties. That’s about the cable anyway, they are using an analogy of like cable ties holding everything together. But if you’re asking, like, Who are you? Who are you tied to? Who are your people, then all of those care coordination things are a lot quicker because you can say, right I remember you don’t have people like your family is sort of not out there. We got to find you people I have and I have people to find you people. But I’m not going to start asking you to do things that I know you can’t do because you’re going this alone. I’m gonna immediately refer you to the to the part of the team that knows how to do that. And we’re you know, we’re cooking up other ones but really, it’s kind of going to the heart of the matter to to find out what’s what’s missing from somebody’s life what what the question behind the question is We have to realize that we’re missing the question behind the question. You know, hopefully there’ll be a four. Ideally, we’ll come up with 10 of them, there’ll be no burger and winkles, 10 commandments. But, and until until we get to that point, you will have to do with the two that I’ve just mentioned that I’m working on a third. I think my third might be start out with the assumption that just because matter was settled the last time doesn’t mean that it’s not going to be unsettled this time. Right. So always have the other stuff in the back of your mind that you thought was over and done with so you don’t get annoyed when you realize it’s not over and done with because I find I’ll start I’ll start
and this gets to the interrupting sometimes I start that is, you know, a patient had benign paroxysmal positional vertigo now they’re in for the nosebleeds are the first thing I’ll ask is, have there been any more episodes of vertigo and No, okay, great, right? The answer is yes. Then Then I don’t get sandbagged with that at the end of the visit where you know, my hands on the door and they go oh, by the way,
I’m still having vertigo, right. So, alright, but I mean, that can also backfire, too, because I’ve gone in thinking oh, this is the follow of this. For the vertigo, and I start asking them like a fairly detailed number of questions again for because because I just because I give advice doesn’t mean I always follow my own advice. I’m asking them questions about the vertigo, three, four or five minutes. And I haven’t asked what their agenda is for this visit. And only after that, do they tell me about the nosebleeds? Which is the reason they came in today? Yeah, right. So it can backfire. But being aware that that might be there, usually, like maybe after they’re done giving a giving a chief complaint, you leave your you know, if we’re going by the old Larry, Larry, we, you know, structured HMP soap note, right, you lead your review of systems with the here are the systems that I’m expecting there to be problems and let’s ask about that right up front instead of burying it at the end.
If you had one, one piece of advice that would be easy for all of us to start doing tomorrow, so like a sticky note that we can leave on right next to our computer for when we’re seeing patients. assuming we’re on an EMR something we can all start Doing tomorrow so that we can start connecting with our patients better and getting to know them better and, you know, maybe slowing down a little bit so we can we can get to that, that question behind the question, what would you recommend writing down on that sticky note? What’s that simple piece of advice so we can all start being a little better tomorrow.
Listen with both ears.
Can you elaborate on?
Yes. You asked for a sticky note, that’s four words, if it’s on a sticky note, what does that mean? So first of all, I have to you know, my disclaimer, I have huge ears. I used to get called Dumbo in middle school. So I have combated that as an adult by growing my hair a little bit longer. But it really resonated with me, I heard it in a eulogy for for a doc in our community. I don’t it’s probably about four or five years ago now. And it just it seems so beautiful. You know, this is Dr. So and So always listened with both ears. And I mean, the first image that came to mind was my It was my friend, Jeff Kurland, who is a pediatric pulmonologist in Pittsburgh who has a double belts down The scope. So he’s actually I feel like he’s listening with both ears, like literally, you know, both sides of the chest at the same time. But after I got that image out of my head, I thought, Well, what does that really mean? When they were talking about this Doc, they meant it one way. And I would like people to remember that which is full attention. Both the words and the property and the nonverbal language is all going in at the same time, you’re not you’re not just listening to the explicit content of what somebody says, but everything, and you’re all there with them. You know, and one of the ways to listen with both ears is to try and minimize the amount of parallel things you have going on outside the exam room at any one time. So like, you know, if you’re the if you’re the doc in charge that day, like making sure things are kind of settled before you go into a room. Like if there was somebody that needed an ambulance that they’ve gotten on their way before you walk into a room while they’re still you know, panicking outside or whatever else is going on. Or if you’re way behind on charts, just own that and be like, I am not going to worry about my way behind on charts until the end of the clinic day. But really, you know, being fully invested in it, including the parts that we don’t always see, including this idea that there’s a question behind the question. That’s the one meaning of listening with both ears. The other one, though, and this is something I spend a lot of time in the in the middle part of the book, there’s a chapter that I talked about sort of a content of words that we say, is listening to what’s coming out of your mouth. And I’ll, I guess I’ll end with my rules about this. So there’s the, the founder of the loan Institute, Bernard Lown, who is, I think, probably 100 years old at this point, but still lives a cardiologist. He was involved in inventing defibrillators and figuring out that you know, if you were on the Jackson and had electrolyte problems, that that could be bad and various other things. Legendary cardiologist founded citizens for social responsibility, a book that he wrote late in his career in the mid 90s. He talks about words that name and words the heel and the doctors say both of these things often and I like to think of you know, the words that Name that come out of your mouth a lot of times are words that stigmatize minimize or dismiss somebody’s complaints, words that frighten people unnecessarily or use fear as a motivator where it’s not appropriate to do so. And most often, actually, I feel like words that confuse people by using clinical terms that the average person doesn’t understand or even plain English terms that are a little bit too esoteric for somebody to follow. Right? I told my medical student yesterday, when you say presents with in front of the patient as like if you’re if you’re presenting a patient to me, and you say so and so presents with don’t say that say, this patient comes to see us today about right and then and then it makes more sense to them to the little things like that. So listening to the words you’re saying so that they’re not harmful? I actually
started drop that in a funny interaction with my wife, where she said, what I said, well, they were communicating. And I was talking about something I don’t know related to something medical, right? Like you like fistula right or too. And, and and she she didn’t understand what that meant. She thought like, they were talking to each other like, it was related to, you know, delivery or you know, somehow and
right. Like
communicating she talking to you. Yeah. What are you typing?
Yeah, exactly. And so yeah, that that’s something that I just took for granted that that right actually sits that,
right. And the flip side of that then is the words that he’ll write words that are words that educate people, words that reassure people. The opposite side of words that dismiss is words that validate kind of like what we’re talking about before, like, wow, that must be really painful. That must really be limiting you and you’re, you know, you’re a roofer. It must be really limiting you that your shoulder isn’t working correctly. Those are validating words. Listen to yourself to make sure that what you’re giving this person is helping them and I think that’s a that’s a really a really good way for us to remind ourselves of what we’re doing. Listen with both ears, both the full attention version and also listen to the patient with one ear and yourself with the other one. Because that’s a way to have a good interaction. And it’s one thing to listen to another person. If you don’t pay attention to what you’re doing in response, you might think that you are a really great listener. But it could have been a really terrible interaction because you heard everything that they were saying and you felt in your heart of hearts that you paid attention, but your responses didn’t convey that back to them.
So healing people, not patients, where can people find
so healing people not patients is available on the Amazon website and thankfully it is now also available in Kindle edition, search up the title or my last name and you’ll find it right there. If you’re looking at my website anyway, which is www healers who listened calm. The first thing that you see is a picture of me with my very favorite older person who was my librarian when I was in kindergarten and directly over that photo is a link to To the book, so, either way,
so you have the website anywhere else people can find you online.
Yeah, so healers who listen on Facebook, which basically digitas gets the posts from my blog. I tweet fairly often on there at healers who listen, there’s no e at the end because there’s a character limit. So it’s healers who lie ESPN. On Twitter, there is an Instagram account. I’m hoping to use that more in the future apropos your last conversation about social media, but it hasn’t really clicked for me how mostly photo website goes with a mostly wordy doctor. So stay tuned. We’re in the same boat.
Yeah, I haven’t gotten the Instagram route either.
But and if you go on the website and go to the blog, there’s a place to sign up to get them delivered to you by email, which I know a bunch of people have done. I just think that’s the kind of thing that will remind me to read it rather than waiting for it to pop out on social media. So Dr. Jonathan
Winkle, thank you so much for taking the time to talk to us, author of healing people, not patients. Thank you so much for your time. Thanks a lot, Brad.
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 a previous guest 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.
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Physicians in Recovery, Part II, with Dr. Sean Fogler

Sean Fogler, MD is the Community Outreach Coordinator at the Pennsylvania Harm Reduction Coalition (PAHRC), a person in long-term recovery, physician and certified recovery specialist. He has over 15 years of experience in the healthcare industry working as a physician, and with patients, administrators, and insurance organizations. This is the second part of the interview. In this portion, we start off discussing how to effectively help friends and colleagues with substance use disorder, the importance of language in this area, and then he tells his story.

Dr. Fogler is active in the recovery community and has a special interest in trauma and substance use disorders in professionals. He volunteers as a peer support specialist for Lawyers Concerned for Lawyers and works to improve public health policy for mental health and substance use disorders. Through his lived experience, he educates, informs, and works to battle the shame and stigma that keeps the disease of addiction alive. Sean’s role at PAHRC involves engagement, education, writing, speaking, fund raising and expanding knowledge of the disease of addiction and harm reduction. Sean holds a bachelor’s degree from The University of Toronto, and a Doctor of Medicine degree from Ross University School of Medicine. He completed an internship in Internal Medicine and a residency in Anesthesiology at Hahnemann University Hospital in Philadelphia, Pennsylvania.

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https://www.paharmreduction.org/ 

https://www.healthprosinrecovery.com/

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https://www.linkedin.com/in/sean-fogler-md-2602aa12b/ 

Physicians in Recovery, Part II, with Dr. Sean Fogler

Sean Fogler, MD is the Community Outreach Coordinator at the Pennsylvania Harm Reduction Coalition (PAHRC), a person in long-term recovery, physician and certified recovery specialist. He has over 15 years of experience in the healthcare industry working as a physician, and with patients, administrators, and insurance organizations. This is the second part of the interview. In this portion, we start off discussing how to effectively help friends and colleagues with substance use disorder, the importance of language in this area, and then he tells his story.

Dr. Fogler is active in the recovery community and has a special interest in trauma and substance use disorders in professionals. He volunteers as a peer support specialist for Lawyers Concerned for Lawyers and works to improve public health policy for mental health and substance use disorders. Through his lived experience, he educates, informs, and works to battle the shame and stigma that keeps the disease of addiction alive. Sean’s role at PAHRC involves engagement, education, writing, speaking, fund raising and expanding knowledge of the disease of addiction and harm reduction. Sean holds a bachelor’s degree from The University of Toronto, and a Doctor of Medicine degree from Ross University School of Medicine. He completed an internship in Internal Medicine and a residency in Anesthesiology at Hahnemann University Hospital in Philadelphia, Pennsylvania.

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!!!

https://www.paharmreduction.org/

https://www.healthprosinrecovery.com/

https://twitter.com/sean_fogler

https://www.instagram.com/sean_fogler/

https://www.facebook.com/profile.php?id=100019053703530

https://www.linkedin.com/in/sean-fogler-md-2602aa12b/

 

EPISODE TRANSCRIPT

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Shawn fogler is the community outreach coordinator at the Pennsylvania harm reduction coalition, a person in long term recovery physician and certified recovery specialist. He has over 15 years of experience in the healthcare industry working as a physician, and with patients, administrators and insurance organizations. This is the second part of the interview, so make sure you listen to Part one first. In this portion, we start off discussing how to effectively help friends and colleagues with substance use disorders, the importance of language in this area, and then he tells his story.
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.
We need to build a better system, you know, and we can do it. We can do it. It’s just the willingness to do it. Right. But it starts with valuing individuals that have a disease if we really believe it’s a disease, because I think the way we act a lot of times is that it’s still a moral failing. Right. And we know that’s not the truth.
You’ve spoken a lot about the importance of personal connection in recovery and the importance in your recovery. And you just talked about that now. So some things I like to happen in the podcast are like advice for people. So let’s say you let’s say I had a friend in recovery, right? My relationship with him or her would be important. What, what can I do for that person? What should I be looking for? What should I be concerned about? What should I be doing to best help my friend, my colleague in recovery,
I think it starts with just having open and honest conversation. I think, I think a lot of us, like we’re afraid to ask. And it might not be just because we don’t, you know, we don’t want to know, but maybe it you know, depending on the answers, we won’t know what to do and, you know, as healthcare professionals, like, we want to fix things, we want to make things better. And I always say, like, you know, substance use disorders or addiction is one of the most complex diseases out there, right. It affects everything, you know, psychological, biological, spiritual, and it manifests differently in different people and what works for one person, you know, doesn’t work for another So I think, you know, having honest conversations, Hey, how are you doing? You know, how are you feeling? You know, does this bother you, because connecting like, having people around you that you know, love you and support you and you’re really connecting in an open, honest way. Like that’s been the most important thing to me. Recovery and many people I know in recovery, that that’s what it’s all about. So open, honest connection.
I, I sounds like you said, be okay that you’re not gonna have answers for them. Right? Like, it’s gonna be as physicians, it’s gonna be uncomfortable for us. If we have a friend going through something, and we can’t help them, but it sounds like the helping them is the listening. Like, you have to get past your own discomfort with the fact that you don’t have answers for this person. Get over yourself. Just ask them and just listen.
Yeah, that I mean that that really, that’s it in a nutshell. We don’t have like, we’re human. We don’t have all the answers. Bad things happen. people struggle. we all struggle, whether it’s in recovery or out of recovery, whatever it is, I mean, we all have struggles and there aren’t always answers or the answers that are there are good answers are the answers we want to hear. And it’s Yeah, it’s being okay with not being okay. It’s being okay with not having the answers. But I think just, you know, having real authentic conversations and and and taking the time to listen, because most people don’t listen. Right? Whether or when they’re listening, they’re listening for what they want to hear. And that’s part of it. And it’s and it also comes down to the whole idea of asking that person, what do you need? What will make How can I help you? What will make things better, and we might not like what we hear with that either. But I think it’s really important to honor you know, their, their own, you know, self agency and, and the dirt because recovery is a process of change. And it’s not our recovery. And, you know, that’s the problem with some of these like 12 step programs and, you know, back to physician health programs, you know, they have a long list of requirements of what you’re supposed to do. But you know, that’s just dictating what we think recovery should be or that and, and maybe that’s not, you know, app now, you know, for healthcare professionals, it is an abstinence based program. But abstinence is not always the outcome, or the or the goal of somebody have an individual right. And that doesn’t mean they’re not healthy. Now, obviously, if you’re practicing medicine, and you’re in one of these programs, you have to be asked, there is no choice. But if you do have a friend that struggles and, you know, maybe they were using cocaine, maybe they were smoking marijuana, but they’re not they’re only drinking now, you know, many people would look at that and say, you know, you’re not in recovery. You’re not doing what you’re supposed to do. But you know, a couple drinks a day you’re going to work, you’re taking care of your family, you’re connected. I mean, that’s recovery for some people, right? So it’s, it’s not all or not, it’s not binary, you know, and it’s Like, the process of recovery is not a straight line. It’s it’s frequently very chaotic. And there’s a lot of ups and downs. And I think the other thing I would say is Be patient, because it’s not a straight line. And just like life, you know, it can be a very bumpy ride.
I think you just answered my next question, which was was, if you were giving a lecture to medical students, knowing that some of them will inevitably face a substance use disorder, some of them will, will face addiction, and they’ll know people as well, you know, some of them will be that person. Some of them will be colleagues and friends with that person. What would you what would be some of the highlights of that lecture? And and I think you just answered that. Right. Well, I answered a little bit.
I yeah, I answered a little bit of it. I think it’s interesting. I was just at Jefferson Medical College, giving a talk to some medical students. So I’ll kind of give you an outline lined up perfect. Well, this was just a few weeks ago, but I you know, I really, I started out with, you know, we need to have honest conversations which I said before, because because we don’t we have whitewash glossed over conversations about these issues. We need to, you know, we need to hear the truth. You know, when I started speaking to the students, I talked about the nature of our current crisis, you know, of substance use disorders in this country a little bit about the history, the data, which is very, you know, enlightening and also that, you know, the the current crisis we have isn’t just, you know, we call it an overdose crisis and you know, a crisis of addiction but you know, we also have a crisis of a communicable diseases, right, HIV and hepatitis C and how all this stuff is wired in and connected and connected to social determinants of health because really, all this stuff touches on, you know, racist drug policies, you know, it’s it’s just, it’s, it’s everywhere and this and that, and I always say policy is worse than the disease and the stigma and the attitudes are worse than the disease. It’s just, you know, people with substance use disorders are some of the most marginalized people in our society. And they suffer. And and I think when students like understand that they, they can become a little more compassionate. And I think, you know, as students, eventually they’re going to engage with people with substance use disorders and that have these struggles and challenges. And so, you know, there’s so much stigma, you know, that’s just built into our culture, and our attitudes. And I think you’re giving them some insight into that, and how to speak to people, right? Even using the word addiction versus a substance use disorder. There’s a big difference there, right, or relapse versus recurrence of use. There’s a whole thing about language and I always say language is a reflection of what we think and believe, right? And a lot of times how we engage with people how we talk to people puts up a huge wall and we don’t even know we put up the wall. And then we wonder, Well, why isn’t this person being honest with me? Well, why would they they don’t trust you. Right you
My first question in this interview is how common is addiction? So you’re saying what I should have said was, How common is a substance or substance
use disorders? Right. And that’s a whole other talk, you know, and I, you know, I’m not the language police, but I, Robert Ashford, who is a friend of mine, and he’s an addiction scientist, here in Philadelphia, he’s done all sorts of research on this. And there’s like, pretty dramatic, like the bias between saying somebody has like, an addiction, you know, versus substance use disorder, like it’s traumatic, you know, he and he’s looking at all this stuff. And it’s, it’s pretty amazing. Like, we dehumanize people with our language, right? We marginalize them. We keep them at a distance, and we don’t even know we’re doing it. Cuz I even catch myself nowadays, even things like, oh, the urine was, you know, in terms of urine drug screens, the urine was clean versus dirty, right? Well, you know, if you’re, if you’re if your urine is clean, you know, people with dirty urines are bad people, right? And it should be positive and negative. And these are like small little subtle things, but they make a big difference. Oh, a
while ago, I did an interview with Stephanie SOG, who’s a psychologist at the Harvard weight center about the use of language in, in patients with weight issues. And that’s what the entire conversation was about. It was right. It was just about how your words the language, shapes, your thoughts, and the language that you use influences the thoughts of those around you. So just by doing something as simple as changing the language you use case now the way people think about things
yeah, and that leads to you know, see We talked about stigma, stigma, stigma, discrimination, and I mean, it’s it’s just it touches everything. So I think teaching students about language, stigma, you know, oppression, you know, all the all these things is really important. I think. I think one of the important things for students to understand is that the mindset of prohibition and the drug policy we have in this country has caused our drug supply to be poisoned, right, and make it more dangerous. And that’s just something that’s happening and changing policy needs to be done. But that’s, you know, that’s a monumental feat, and it’s going to take time, but until then, I think they need to understand harm reduction, the philosophy of harm reduction, right, why it’s important to supply people with Naloxone, you know, when you’re prescribing opioids or if they have an opioid use disorder and they’re using these drugs. I think you know, when you Supply people with, you know, teach students about drug testing equipment, and how people can test their supply. You know, because it’s been shown, you know, they’ve done research at Brown and at Johns Hopkins and shown that people who use drugs, want this want to be able to test their drugs and will actually change their behavior, depending on what those tests show. I think they ended up need to understand Good Samaritan laws. You know, and then I would, you know, tell them a bit about me my story and how I got there, you know, got to where I’m at today. I think that’s
a great segue. I think this is right, because our intention was free to tell your story towards the beginning, but I think I think this would be a great time for it. Sure. So. Yeah, so
what’s your story? So I,
you know, I came to the United States. I’m actually originally from Canada in the mid 90s. And I came here for medical training. And ultimately, you know, my journey ultimately took me into medical school, which is something I always wanted to do. And I actually started out surprisingly in podiatry school, and I actually did two years dietary before I went to medical school, which I don’t usually talk about, but I was, yeah, I didn’t really like feet. And so I ended up in medical school. I
know.
I’ve had kind of a long winding road. But yeah,
you ended up as an anesthesiologist. And if people had trouble finding, you know, a vein, you’re you were there at the feet. Right, you’re able to get access there because you knew the anatomy a bit better than anybody.
Exactly. And so, when I finished medical school, one of the senior my whole my actually my entire most of my family is is in finance works in finance, and I thought that I could meld scientific knowledge with you know, with the finance industry and I wanted to actually research pharmaceutical companies and provide that that information in the in the finance world and and so I went and actually worked for a couple different firms in New York. And this was around the year 2000 2001 which for me put me next to the World Trade Center during the 911 attacks. And I had you know, as a kid, I had used substances but, you know, I smoked a little marijuana I drank a bit, but I never
I mean, substances weren’t a thing for me, really ever.
And I was pretty athletic through high school and early in college and played sports or Amtrak and it just wasn’t something I thought about but after the 911 attacks, and I was there I worked about three blocks away, I developed PTSD. And it’s really interesting because I was so I guess traumatized and disconnected that I didn’t. I didn’t, I didn’t really have any insight into the extent of the trauma and how it affected me. And when I look back on it, like I, you know, I remember that day very vividly. I remember moments during that day when I thought that I was going to die. And I also remember a specific moment where every something changed in my head. You know, there was there is almost like a switch went off. And everything was different from that point on and it’s just it’s really interesting, you know, I mean, I always say like, like trauma is at the root of, I think the majority of people with substance use disorder and and that trauma doesn’t necessarily early have to be something catastrophic or massive, you know, like, like I went through, I think it can be subtle things, it depends on the individual, and something that, you know, you and I wouldn’t have an issue with somebody would and so, you know, trauma was it was at the root of my substance use disorder. And, and initially, you know, I went back to work, I knew I wanted to get out of New York, and eventually I applied for residency to go back to residency because I had initially matched after medical school. And then I reapplied Two years later, and I came to Philadelphia for a residency and Anastasia, and I really was just floating through life and going through the motions. And, amazingly, I think part of the way Well, I know part of the way I coped was just working really hard. And I threw myself into work and I was, you know, it was a really good resident. In fact, I was not nominated for for a teaching award during my internship, and I did I did well, you know, I moved into my anaesthesia training. And, you know, early on, I knew things were right. And I definitely had some depression. And I went, I went to a couple physicians and I was prescribed some antidepressants and I tried a couple different ones and I didn’t like it and probably like a year into training, I was introduced to cocaine and cocaine made everything better. I mean, it really it, it just changed everything. I felt great. I felt energized. I wasn’t down and really the first, you know, probably few years that I was using it. It was pretty intermittent and casual, but, but it helps a lot helps a lot. And so between work and a little bit of drug use. You know, I’m move through residency and I finished residency. And I was successful. And I actually, when I finished residency, I got a spot as a fellow in critical care medicine Medicine at the University of Pennsylvania, which I didn’t actually do. I got the spot. And I decided, like, last minute, you know what, I’m going to go into private practice. But I think looking back on it, I kind of regret that I didn’t do it. I think I think part of the reason why I didn’t do it is I didn’t think that I would be able to act the way I was acting, use drugs the way I had started to use drugs, and get away with it there. And so, you know, I just, you know, looking back now, I can see that at the time, I didn’t, I just was like, Ah, that’s not for me. I think I’m gonna go, you know, I just want to make money and go into private practice. And so, so I did and I was doing well in private practice, and I and I practice for about 10 years. And, you know, bit by bit, as Sometimes I wish something catastrophic happened earlier, but but it really didn’t like this was a very slow progressive kind of dive into the abyss. Like, it wasn’t like, you know, I got PTSD and everything fell apart, my life fell apart, I was able to hold it together. And I think because I was successful, and I was making money, and I had good jobs, and I did really well at work.
Everybody thought everything was fine. You know, and I think like that, I think that’s one of the huge risks for us, like as, as medical professionals, and as healthcare professionals, when you’re doing well, and you can dress it up and kind of wear the mask. Everybody thinks things are great, you know, in fact, you know, many people look at you and are like, oh, that guy’s got it all or that girl’s got it all, you know. They’re doing all the right things doing great work, look at the car, they’re driving, look at their house to live in, you know, the kids are great schools, but that doesn’t mean everything’s fine. And for me, it definitely, you know, I was not fine. And really our women don’t realize.
So because you mentioned like the slow descent and it seems so gradual that you can kind of rationalize everybody.
Exactly, which is what which is exactly what happened. And you know, even like, even like my, my wife, I think she tolerated a lot of my behavior, which, you know, years later from talking to her like she knew stuff was something was wrong, but she tolerated it because I was going to work every day. I was making a lot of body it just it seemed like everything was fine. You know, on the surface. She knew something was wrong, but clearly it wasn’t bad enough that the real bad things you know, hadn’t started happening. And yet, so she in some ways, not intentionally just allowed it to progress and didn’t really call me out and just was like, Well, okay, this is how it is and when a lot and that’s no fault of hers, right and also, you know, she, she, you know the people around us who love us don’t want to believe that you’re sick that that something is off you know something really wrong it’s going on which she knew, right her instinct was telling her and it wasn’t until I would probably say like so I went to rehab in the in the spring of 2015. And I would say the year before is when things really got bad. I had I had started a practice with another colleague of mine so I was making my own schedule, but I was like not working as much. You know when some of my bad behavior started to come out And I just, and the drug use was just escalating. And I eventually met this woman who had a substance use disorder far worse than me. And that was like the person I hung out with to do drugs, you know, and she wasn’t in my circle, and I figured it was safe. Of course, you know that, that logic didn’t make any sense whatsoever. And I remember standing in my kitchen. This was like, I don’t know, maybe March or April of 2015. And my wife holding my son who was very young at the time, like, less than a year old, probably and saying to me, I don’t even recognize you anymore. And me replying. What do you mean? Like it’s me, and, and that’s the first time I realized, wow, something’s wrong. Like I don’t even realize that I’m a different person. And And that was it. Like, that’s what I was like, Okay, I’m ready to go away, I need to get help. And that changed everything for me. So I voluntarily went away. And I spent four months down in rehab, I went to a place in Florida and then I went to a place in Kentucky for a couple weeks, that specialized in PTSD. And it was amazing. I mean, it was incredible. And I, everything changed for me. You know, every everything changed the way I looked at the world, the way I interacted with the world. I mean, it wasn’t a straight line. You know, at that point, my wife was ready to leave me pick up the kids and go but when I got back, you know, and she saw the chain is she she hung around, you know, and, and having that support was really crucial early on. I mean, it was so important. Um, I always say I don’t understand how other people that don’t have the love support the resources around them are able to run recover because recovery itself is it’s like climbing Mount Everest. I mean, it is it is.
It’s definitely the toughest thing I’ve ever done hands down, you know, but the most rewarding and so I got home and I didn’t work for probably another four or five months, I was going to meetings constantly I was I dove into recovery, you know, I was exercising or spending time with my kids. I mean, things were good. And then I got a job practicing anesthesia again and I started to work again and I you know, work was great. And yeah, I mean, I you know, I had that purpose back and because of my entire experience. I decided that I wanted to I didn’t know if I was going to switch specialties entirely but I figured you know I could do a little anesthesia and also practice Addiction Medicine. So I applied for a fellowship at Karen treatment centers with reading hospital here in Pennsylvania, which is like they’re like the Hazleton Betty Ford, you know, kind of over on the East Coast here and I and I secured the fellowship, I got the had one spot and unbelievably I got it and I was super excited. And there were so many great people there. And, and in July of 2016, I started the fellowship and three weeks into the fellowship, I was arrested for, for writing some prescriptions to the individual that I was hanging out with in like 2014 so about two years before I had written about seven prescriptions to this girl. And and that was awful. I mean, that was that was I was like how can this even be happening? I mean, this is just said you know was very shameful.
You know that, you know, made it to the top of Everest.
I had made it to the top right I had made it to the top and then you You know, I got whacked, you know, I got knocked down, you know, lower than where I started before. And, you know, as, like, we don’t talk about this but as physicians, you know, and like we are high profile like, and we are in the line of, especially with the current overdose crisis and with what’s going on with opioids. I mean, we are in the crosshairs and we don’t even realize it. And so, I you know, I was considered Oprah high profile, which is ridiculous, because, you know, to me, I was, you know, I wasn’t, I wasn’t running a pill mill, but I’ll just say, you know, I was like, Okay, I, I definitely did some stuff that was wrong. I accept responsibility, but the prosecutor in the county, and this isn’t, you know, Philadelphia, you know, Philadelphia is a very different place than the rest of Pennsylvania. And you know, our district attorney here is Larry crasner is extremely progressive. I mean, this city is doing some amazing things in terms of criminal justice. reform in terms of the opioid crisis, which we have a massive problem here, but if you step outside this county, which is where I was prosecuted, the mindsets are extremely narrow, you know, and very fixed. They still many of these counties view substance use disorders as a you know, moral failing. If you’re a doctor, right, it’s they want you because they want to show they’re doing something and this prosecutor, you know, the line that I kept hearing, because and my prosecution went on for two years, so from 2016 so my license was suspended you know, immediately and for two years, I basically was waiting around man the prot and what I kept hearing was the prosecutor was like, you’re a doctor, you should have known better, right over and over. And I was like, Man, I wish it was that easy. Like if that was the case. You know, doctors wouldn’t have substance use disorders. You know, lawyers wouldn’t any professional anybody with half a brain but it just doesn’t work that way, it was really all about politics. And as soon as your face it’s the paper, they can’t back down, right? It’s all about winning. It’s not necessarily about justice. And so, you know, ultimately, that wrapped up at the end of 2018. Luckily, I didn’t go to jail. So that was great. But in Pennsylvania violation of the controlled substance act is an automatic 10 year suspension of your license, which is outlandish as well. You know, that’s a whole other conversation. I’m also licensed in New Jersey, which is usually three years, you know, theoretically, I could have had my license back in Jersey, but when you have multiple licenses in multiple states, you know, they always go with the more stringent one, you know, and I also have a Florida license, which is really interesting. That’s a whole other story, but I was recently down in Florida, going in front of the board, and I told them my story, and they they were considering giving me my license back right away. But you know, there was A whole political thing? Well, you know, his license is still suspended in Pennsylvania. And so, you know, that’s the short of it. And, you know, it was, it was so you know, the legal thing was so challenging. There’s so much shame, so much professional stigma and isolation and, you know, in recovery, it’s all about like connection and getting that support and the legal thing, you know, that created even more like, you know, isolation and thankfully, I had some good people around me, you know, the recovery community, the physician recovery community, and I got a lot of support, and it just made my recovery stronger, you know, and then I got connected to the organization I work with now the Pennsylvania harm reduction coalition and doing all this drug policy work and I’m training law enforcement across the state and which was really scary at first, understandably and intimidating, but, you know, it’s been really good and you know, they appreciate my story. Worry and the honesty and, you know, I think, you know, one of the benefits is that my story is helping them see this in a different light, you know, which is, which is pretty powerful, you know, and I’m hoping I can, you know, use my story and my experience to change some of this this policy and educate people and do different things. And I think, you know, at some point, I will try and get my license back. I don’t know if I’ll ever practice again, but I do want it back and, and that’s kind of how I got to where I’m at today.
I think it would be incredible if you did if you did that fellowship and Addiction Medicine, right, all of the people that you get it more than those who haven’t been through the struggle. Yeah,
right. Well, that’s the lived experience apart. That’s what that’s so valuable. It’s a valuable piece.
And and I think Viktor Frankl would be would be proud, right. You found Your, your, your meaning, right? And in your struggle you found now you’re making all of these connections and helping all these other people because of what you went through.
Right? Right. And that was and that was the most, that was the most painful thing, like when my license was, well, you know, the face in the paper and then my license getting suspended. I was like, What am I gonna do? Like more than anything else, you know, more than the shame and you know, my colleagues, some of my colleagues turning their backs on me was like, What am I gonna do? Like, I want to do something, you know, I mean, all of us were like, we’re high achievers. We like to work smart or creative. I was like, What am I gonna do? I can’t do anything. Nobody’s gonna hire me. I’m like, I’m done. And it was like searching for a purpose searching for a meaning. And I was like, how do I turn this into something that is going to mean a lot to me and mean a lot to other people. And it’s You know, and it wasn’t like, Oh, this is it. Like, it’s just, this has been a slow process, you know, in something that has just, you know, something that’s just kind of been born like just emerged, you know, and it’s and it’s still it’s still changing, right? It’s still happening. And I have no idea where it’s gonna lead and that’s like really scary. But it’s but I’m starting to enjoy that because like when we practice medicine, like we’re just certain right like you do pre med, you go to medical school, you do your residency, you’re out practicing, we have a path, it’s
if you follow the rules, and if you do you do well on your tests, then everything will be okay, you’re
set, and it’s comfortable having a path right and and when you get far enough along the path, like you know, the financial rewards are great and the respect for the most part, like communities grade and you know, you’re looked at a certain way and treated a certain way and then you lose it all. And it’s like, what am I going to do? You know, and
I think that’s a testament to the strength of your recovery.
Yes. And, and, and more so to the people around me cuz I like I, you know, it’s not like people are like, Oh, you know, you’ve done so much you’re doing so great and I’m like, but it’s, it’s because of everyone around me, you know, my family, my friends, physician recovery community, the recovery community, you know, guys like you like, have me on it, you know, I’m honored and humbled that you would even invite me to speak on your podcast, you know, everything I do, you know, I’m just eternally grateful for and that, like, that’s been a massive gift for me because before I just expected it, like I did, and even though you know, I think my, you know, the core of my characters the same I’ve changed like the way I view the world, the way I look at people and things I just have a whole other approach. For Life, the people around me and and that’s a massive gift because I didn’t see it before.
I think I think though the work that you’re doing is, is incredible. I mean, I appreciate that. You appreciate me having you on the podcast. That really means a lot to me. Because it you know, I never know who’s listening out there, but but all the work that you’re doing is it’s incredible. So So tell the listeners where we can find you and follow all the great things you’re doing. Tell us about your podcast and any online presence that you’ve got.
Sure. So myself and another nurse in recovery. Bill kinkle have a podcast called health professionals in recovery. I think we have six or seven episodes now. And it’s I mean, it’s for everybody, but it’s focused on healthcare professionals. And we’re trying to speak openly and honestly, about substance use disorders and the challenges as Practicing healthcare professionals, something that that most health professionals that are in recovery are not out there speaking and so we’re trying to open that up. I work for the Pennsylvania harm reduction coalition. So pa harm reduction coalition.org we do a lot of drug policy work, advocacy work, harm reduction training, public health. We work with law enforcement, the medical community, you know, tons of loads of community organizations doing all sorts of work from treatment industry providers, to to organizations that you know, are involved in policy, we do a lot of government work. We’re kind of everywhere. You could check us out also on Twitter and Instagram. And if you look, you can find me on Facebook at under my name is Shawn fogler. And Sean underscore fogler is my twitter and Instagram as well.
We’ll be linking all that up and in the show notes. So I really appreciate you taking the time to come on the show and and sharing your story with us. I think a lot of times physicians forgot what it’s called. But we’re like ducks, right? Seems seems like we’re all calm on the surface, but then you look beneath the surface and we’re just kicking and kicking and kicking and kicking. And I think it’ll help a lot of people that you were vulnerable enough to share your story and your struggle with us so that they can, they can relate and realize that what they’re going through is what other people have gone through and are going through. And I think that’s, that’s a tremendous help to know that you’re not, you’re not the only person going through this, you’re not alone. And there are people out there that that can help and, and all the advice that you gave for, for who to who to go to and who’s been the most helpful in your, in your struggle. So I really appreciate all of that.
Thanks so much.
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

Physicians in Recovery, Part I, with Dr. Sean Fogler

Sean Fogler, MD is the Community Outreach Coordinator at the Pennsylvania Harm Reduction Coalition (PAHRC), a person in long-term recovery, physician and certified recovery specialist. He has over 15 years of experience in the healthcare industry working as a physician, and with patients, administrators, and insurance organizations. This is a two-part episode. In this first part, we talk about how common a substance use disorder is among physicians and why we are at higher risk than the general public. He then gives guidance on where to go to seek help if you have a substance use disorder. We discuss Physician’s Health Programs and some of the positives and areas for improvement of those programs. He then discusses some critical elements to recovery.

Sean is active in the recovery community and has a special interest in trauma and substance use disorders in professionals. He volunteers as a peer support specialist for Lawyers Concerned for Lawyers and works to improve public health policy for mental health and substance use disorders. Through his lived experience, he educates, informs, and works to battle the shame and stigma that keeps the disease of addiction alive. Sean’s role at PAHRC involves engagement, education, writing, speaking, fund raising and expanding knowledge of the disease of addiction and harm reduction. Sean holds a bachelor’s degree from The University of Toronto, and a Doctor of Medicine degree from Ross University School of Medicine. He completed an internship in Internal Medicine and a residency in Anesthesiology at Hahnemann University Hospital in Philadelphia,

Pennsylvania.

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!!!

https://www.paharmreduction.org/ 

https://www.healthprosinrecovery.com/

https://twitter.com/sean_fogler 

https://www.instagram.com/sean_fogler/

https://www.facebook.com/profile.php?id=100019053703530  

https://www.linkedin.com/in/sean-fogler-md-2602aa12b/ 

Physicians in Recovery, Part I, with Dr. Sean Fogler

Sean Fogler, MD is the Community Outreach Coordinator at the Pennsylvania Harm Reduction Coalition (PAHRC), a person in long-term recovery, physician and certified recovery specialist. He has over 15 years of experience in the healthcare industry working as a physician, and with patients, administrators, and insurance organizations. This is a two-part episode. In this first part, we talk about how common a substance use disorder is among physicians and why we are at higher risk than the general public. He then gives guidance on where to go to seek help if you have a substance use disorder. We discuss Physician’s Health Programs and some of the positives and areas for improvement of those programs. He then discusses some critical elements to recovery.

Sean is active in the recovery community and has a special interest in trauma and substance use disorders in professionals. He volunteers as a peer support specialist for Lawyers Concerned for Lawyers and works to improve public health policy for mental health and substance use disorders. Through his lived experience, he educates, informs, and works to battle the shame and stigma that keeps the disease of addiction alive. Sean’s role at PAHRC involves engagement, education, writing, speaking, fund raising and expanding knowledge of the disease of addiction and harm reduction. Sean holds a bachelor’s degree from The University of Toronto, and a Doctor of Medicine degree from Ross University School of Medicine. He completed an internship in Internal Medicine and a residency in Anesthesiology at Hahnemann University Hospital in Philadelphia,

Pennsylvania.

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!!!

https://www.paharmreduction.org/

https://www.healthprosinrecovery.com/

https://twitter.com/sean_fogler

https://www.instagram.com/sean_fogler/

https://www.facebook.com/profile.php?id=100019053703530

https://www.linkedin.com/in/sean-fogler-md-2602aa12b/

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. Shawn Vogler is a community outreach coordinator at the Pennsylvania harm reduction coalition, a person in long term recovery physician and certified recovery specialist. He has over 15 years of experience in the healthcare industry, working as a physician, and with patients, administrators and insurance organizations. This is a two part episode. In this first part, we talked about how common is substance use disorder among physicians, and why we are at higher risk than the general public. He then gives guidance on where to go to seek help if you have a substance use disorder. We discussed physicians health programs, and some of the positives and areas for improvements of those programs, and he then discusses some critical elements to recovery. Sharon is active in the recovery community and has a special interest in trauma and substance use disorders and professionals. He volunteers as a peer support specialist for lawyers concerned for lawyers, and works to improve public health policy for mental health and substance use disorders. Through his lived experience, he cades informs and works to battle the shame and stigma that keep the disease of addiction alive. Sean’s role at pH RC involves engagement, education, writing, speaking, fundraising, and expanding knowledge of the disease of addiction and harm reduction. Shawn holds a bachelor’s degree from the University of Toronto and a Doctor of Medicine degree from Rockford University School of Medicine. He completed an internship in internal medicine and a residency in anesthesiology at hanaman University Hospital in Philadelphia.
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. Sean Faircloth, thanks so much for being on the show today.
Thanks for having me.
So let’s start with the macro view of addiction in physicians and then get to more of the micro view. So first, how common is addiction in physicians?
Well, I mean, this is something that’s that’s actually very common, more common than I think many of us realize. In the general population. They say you people with a substance use disorder are around nine to 10%. It’s hard to know exactly with physicians, but the numbers seem to be somewhere around 15%. And that can vary actually with specialties. So anesthesiologists tend to have a little higher rate psychiatrists, except especially female psychiatrists tend to have a higher rate. So it does, you know, there’s no exact answer, but it’s more common than it is in the general populace. Why do you think that is? Why do you think we’re at higher risk? I think there’s so many different factors. You know, even if you just look at General factors for addiction, your psychological biological things like anxiety, depression, we work at a very high pressure, high stress environment where lives are at stake. And, you know, I think a lot of it has to do with the systems we’re in and especially nowadays, as you know, with electronic medical records and more administrators looking for data and pushing us to work you know, longer, harder, faster. And this causes you know, the you hear about burnout and compassion, fatigue and trauma, vicarious trauma, almost like PTSD in a way where people can feel very isolated, they don’t feel valued, and I think one of the one of the most important areas that leads to substance use disorders in physicians is the culture of silence, where we really we don’t feel safe to come out and share, hey, I’m stressed out, hey, I feel depressed. Hey, I think I’m drinking too much because because of professional, you know, judgment, fear of consequences, right? If somebody reports you to, you know, your chief or to the medical board, the consequences can be quite dramatic. So I think we have a culture of silence that we don’t talk about this stuff. And I think many institutions talk about, you know, improving the culture, creating wellness programs, but I really, it’s almost like lip service. It’s like this is what we’re supposed to be doing. But they’re not really providing the time, the energy and the most important thing is probably the safe space, right, a space where you can share your struggles without fear of retribution and Anyway,
this seems to be a theme in our profession. I had an interview a little while ago with Stacey Dearman about litigation. And that’s something that we’re not allowed to talk about, right. Like, if you’re if you’re involved in a lawsuit, you know, let’s talk about it. And that actually has led to physician suicide, right? Because you’re allowed, you’re, you’re, you’re involved in this, you feel terrible about something that happened, and then the lawyers use this against weaponize that against you. And then, you know, you’re, you’re you’re already in a extremely high stress situation, you know, and that and that has, on occasion turned out to lead to suicide. So this the fact that we’re so siloed, and that all they’re doing is paying lip service, right? They create a wellness program because they’re supposed to now, what’s the science and the data behind a wellness program? I actually don’t know offhand, but I would assume very little. Whereas the Safe Space seems to be really a great solution to this problem, but What What is their solution? Aside from the wellness programs, let’s say let’s say you do have a substance use disorder and you want to seek help. What is our current system for that?
Yeah, it’s the system is not good.
It really is good because it like, it’s funny. I was thinking about this the other day, and there’s, you know, I was thinking about all the, all the things that you that an individual physician can do, if they feel like they’re struggling with a substance use disorder. And the last thing on my list was the physicians health program, right, which is, which is awful. And it tells all because, you know, a physician’s Health Program, which is supposed to be about health and wellness for practitioners is a monitoring agency that says they’re about physician health and wellness, but what they’re really doing is protecting the medical board protecting the institution. And they’re monitoring agencies. And so like, I mean, if I if I had, I mean, it starts with being honest, which is really hard when somebody does have substance use disorder, I mean part, just part of the disease is, is isolation. Like I always say addiction or substance use disorders are diseases of isolation. And you become disconnected from yourself and from reality so and from the world around you. And so and as all these it’s rooted in fear, and shame, there’s a tremendous amount of shame. And so, like, I think, you know, starting with your family, if you can talk to your family, I think having a therapist or connecting with a therapist, is a great place to start. mutual aid groups like a and na are great places to engage with people if you know if you can take that step which is really hard at first really, really hard There are recovery communities. There’s produces meetings, which, you know, I’ve been going to produce meeting for almost five years now. Where it’s just doctoral level healthcare professionals. And those are great places to anonymously, you can, you know, you can contact employees as since programs. So, there are a lot of things, the last place I would do is, the last thing I would do would be pick up a phone and call a physician’s health program. Or even talk to your like, I think, you know, talking to your colleagues talking to senior clinical, you’re the chief of your department is, is tricky, you know, some places, that’s probably a great thing to do, and beneficial and in other places. It can be catastrophic. You know,
ultimately, you don’t know what they’re, what they’re going to do with that information, right. Whereas if you’re with With a therapist, aren’t they obligated to keep it confidential?
Exactly. And that’s the first place I would start. You got you have to find somebody who’s trusted. And where you can share this stuff in a in a safe space. I mean, that is, that’s, you know, and that’s one of the other things I do on the side. And you know, he can get into it. You know, a little bit more later, but I were I volunteer for this organization called lawyers concern for lawyers. And they provide peer support to lawyers, judges and their families and law students as well. And they do a better job than we do. They do a much better job than we do. And it’s all anonymous. The goal is to get you back to work healthy and whole. And it’s not punitive at all. Obviously, there’s extreme examples. I mean, if you land in the paper You know, you know your substance use disorder takes you in a direction that leads to something traumatic. There will be more monitoring. But in general, it’s it’s a more it’s a softer general way, gentler way, and approach that’s rooted in the idea of getting you healthy and back to work. And, you know, with physicians health programs, it’s not like that at all.
You know, you keep going, you keep mentioning these physician health programs, and I think it bears discussion what what this is, so, I’ve heard you if I hadn’t listened to your podcast, I don’t think I’d know what a PHP was. So what is it? What?
I had no idea what it was until I landed it myself, but a physician’s Health Program is a program and and almost every not every state has them but almost every state has them and they kind of operate in conjunction with that. Medical Board at a focus on physician health and wellness. And it’s usually physicians that are struggling with substance use disorders. Sometimes it’s behavioral issues. For a substance use disorder, at least in the state of Pennsylvania. What happens is you sign a five year contract the physicians health program, and your license usually stays intact. And there’s no public reporting of your issue. And there’s certain things that you have to do and one is going to therapy. One is going to group therapy. The other thing is either going to a certain number of 12 step meetings every week, which need to be logged in it. It also involves random urine testings, screening, and so and depending on the individual, there may be some other other requirements as well. And as you progress through it, the testing goes down eventually you don’t have to do group therapy and If If you listen to the physician health programs, you know, they have very high success rates. And, you know, that’s we don’t know. See, the problem is there’s there’s not really any oversight to physicians health programs. So we and we, they don’t share their data. So we don’t know the exact numbers, but historically, they claim very high success rates. That’s that’s kind of the short of it.
So what that sounds reasonable, right? Yes. Go to group therapy. There’s a monitoring program, because part of the reason this exists is it’s a patient safety issue. She has to make sure that the practicing physicians that have a history of substance use disorder aren’t actively using substances. This all sounds reasonable. However, there are some flaws in their system. What What would you say the those what, where’s there room for improvement in the system?
I think I think if it’s really like if these systems if these programs are really about health and wellness, I don’t think a cookie cutter approach is the way to go. And they really plug everybody in, for the most part into the same general program. And like, for me, I didn’t have an issue with it. When I entered the PHP, I was a year and a half into recovery. You know, I had no prob I was already doing therapy I enjoyed group, I was a 12 step person, but some people find it, you know, they, they either they’re not on board with 12 step, you know, maybe, you know, their religious background or they’re atheist, and they struggle with that. Somebody, why would that be? Um, you know, 12 step programs are problematic for some people that, you know, it’s all you know, it’s rooted in the idea that there’s a higher power, the first step and yeah, it will admitting your budget. powerlessness, you know that you’re powerless over drugs and alcohol. You know, that’s the first step. But some people find that problematic, right? And so it’s interesting, there was just a lawsuit and this is in Canada in British Columbia of a nurse, that that was denied his license. And he was in recovery, because he refused to go to 12 step programs. And this went, I think, all the way to the Supreme Court, and he just won. There was actually an article on it yesterday that he should not have to be required to do these meetings right now. There’s other stuff because recovery, you know, recovery isn’t just 12 step like recovery is many things to many people. And I always say it changes over time. So like, you know, to me, recovery is going out for a run, right or, or, or being connected with, you know, friends or family or you know, reading or meditating like, it’s not just 12 step in some of these rooms. programs. I mean, it doesn’t sound like a big deal. But when you’re forcing somebody, it’s almost like forcing someone to practice a religion for eight for a certain amount of time that they absolutely are opposed to. And that’s really not honoring their lives and you know, their life and their beliefs. The other thing is, we don’t have any evidence, the 12 step programs necessarily work like they work when they work. I found it very helpful. Some of my colleagues don’t find it helpful at all. And, and other colleagues find it actually harmful, you know, when they really struggle with it.
So I think we have to, you know,
like recovery and substance use disorders. It’s really different for different people and it’s not like you know, if you have hypertension, everybody’s and get the same drug feed everybody doesn’t get the same diet. Like, it doesn’t work that way, if it’s a disease, we should treat it like a disease. And, and the solution is not always the same. And it’s problematic. And the other, like, just the starting point to looking at these programs is they should be, we need to see their data, right? We don’t really know what’s going on behind closed doors, and you hear horror stories all the time of physicians committing suicide, you know, being homeless on the street. And, you know, for the right person that works. And for other people, it doesn’t necessarily work, but because it doesn’t work doesn’t mean that they’re not doing the right thing. Like, like the program itself can be a huge barrier, you know, to recovery.
And then if they feel like that’s not working for them, then they feel like there’s something wrong with them. Why is it working for everyone else? It’s not working for me, there’s something wrong with me. And then that’s gonna push them backwards,
right and then and then think about the stakes right? So it If you don’t do what they say, you don’t have a license, and then there’s public disclosure, right? So they report you to the board, the board posts something publicly, your license is suspended, you can’t work. Right? There’s a whole cascade of events that occurred that your life is and there, there are physicians that are broke, that are homeless, because they’re not able to, you know, to move through these programs and do what is required. But that what they are requiring doesn’t necessarily mean you’re successful and you’re healthy, right?
It just means you jump through their hoops in the time jumping right? To do it. Yeah,
right. And and addiction, you know, addiction is a chronic progressive relapsing disease, you know, stress induced, like if you look at the A Sam definition, but after five years, you get your seal of approval, and you can go and do whatever you want. Right, which is just that doesn’t even make sense itself, right. And my whole thing is like if we really are concerned about protecting the public, if we’re really concerned about physician health and wellness, the people that the physicians that are in the hospital or you know, in the clinics, offices, you know, all over the country, that, you know, we should be providing support for them. Right, like, they should be getting therapy, you know, they should be going into groups. And, you know, and and, you know, this is controversial, but, you know, should we be testing them, right, pilots get randomly tested. I mean, I’m not advocating for that, because tests, you know, drug and alcohol testing is problematic. It’s, you know, in and of itself, but we’re not doing anything for those. We’re just taking a select group that had an issue, putting them through some program that maybe, you know, maybe it has a great success rate. Maybe it doesn’t. There was a recent article in the New England Journal of Medicine, by Leo bell. Lenski and Dr. Sarah Wakeman up at Harvard, and the articles entitled practice what we preach and it’s really focused on opioid agonist therapy for people with opioid use for physicians with opioid use disorder, which is Suboxone? Right? And in these programs, Suboxone is a no, no. Right? You can’t be on Suboxone or buprenorphine or methadone and practice medicine and have a license.
What’s the reasoning behind that? That’s,
well, they, there’s no, you know, absolute, but, but the general thought thought process is, is that you’re impaired if you’re on these medications, but we don’t have evidence. We don’t really have good evidence on that. But what about, you know, a physician that takes Ambien at night or takes, you know, a Xanax or you know, some other benzo to go to sleep or is on some other site Could trophic you know, met some of these antidepressants? Are they in? No, it comes down to stigma, and are deeply rooted attitudes that these people are sick and flawed, you know, and are not safe. But we, but that’s not the truth. And it’s great, you should take a look at the article if you get a chance because it and I always say like, that’s the tip of the iceberg because it brings into questions so many of our attitudes towards our own colleagues, right. Like I always say, how we treat our own tells us everything we need to know, right, so, so how, you know, I treat my colleague who’s struggling with a substance use disorder really, you know, shows us what we’re thinking and what our beliefs are. And I think the stigma and the attitudes within the medical community towards people with substance use disorders is the is the worst is among the worst and I’m not there are some great people doing great work out there. But I think Jim In general, and as a system, we don’t do a very good job. When
you if you are building a PHP program from the ground up, right, let’s in this that seems like it’s state to state, right, like,
well, that. And that’s the other problem. It varies from state to state. So these programs aren’t even uniform.
Right? Like, interesting, we should be able to use that data then right? If there’s different you can you can then compare which ones are more effective, which ones are less effective? What’s the differences between them to try and figure out what are the what are the aspects of it that really help our physician colleagues? The best?
That’s a great idea.
Let’s say you had free reign, right? of over, you’re in Pennsylvania. Let’s give you a New Hampshire. I just chose that random. Random, right. You get to build it, you get to build it yourself. How would you do that? What would you what would the PHP consists of?
Wow. That’s I mean, it’s a great question. I I think I would start with sitting down with a group of physicians that have had substance use disorders in the past, currently have substance use disorders and talk to them about exactly what are their wants and needs and like from my understanding and what I know about recovery you know, having connection having support having purpose is critical. Right. So, you know, when it comes down to, you know, the safe space like making, like, we have to change the culture will people, you know, put people in a place where they can open up and connect with their colleagues, you know, obviously there would have to be a treatment component, an education component. I think he would have to involve hospital systems, you know, senior leadership and hospital systems and have them involved in the in the program and just creativity. program where people can share their struggles get the support they need. And this is gonna, it’s gonna vary because, you know, some of it has to do with trauma. A lot of it has to do with trauma and and dealing with trauma and every individual is going to be different. Right. So I just, you know, to create one entire program, I think, I think the way you know, the lawyer is concerned for lawyers does it where there’s an anonymous component where you’re protected, where you’re referred, you know, in a confidential way to different resources that can help you and connect you I think peer support is a massive part of this. Being paired up with somebody with lived experience that’s been successful that can guide you through and support you is really really important in all of this like it’s like it’s like as like a sponsor, but I think more than a sponsor because you know, especially Sponsor takes you through the steps of whatever program it is, say say that a peer support is much more you know, peer support is someone you can look to and say, Hey, like, he’s had these struggles, or she’s had these struggles and has been successful. And this is what they did. And this is how they got there. And a sponsor doesn’t necessarily do that for you. I mean, a sponsor can be very important and is a really good sounding board. But I think somebody you know, appeared, peer support is like the next level. And it’s like, seeing is believing because a lot of times you get into recovery, and things are bad things are really bad. And life seems hopeless. And, you know, we’re always comparing ourselves to other people. And unless you can see a path forward, it can be very, you know, and I’m like a pretty village, you know, individual that had a ton of, you know, support and abundance of resources that led to a very strong recovery. But most people don’t have that. And everybody should have that, you know, everybody should have access to that. And I think aspects of the PHP are important. I think group therapy is really important. I think having a group of people around you that get to know you, they can call you on your bullshit and give you insight into yourself is one of the most powerful things you can do you know, group a group therapy, peer support, and support at work in the workplace because I think getting back to work, you know, assuming you’re in a mental state, where you can be successful is one of the most important things and I was taught I was talking to somebody the other day about Victor Frankel’s book, Man’s Search for Meaning.
That’s my Bible like that. Is
Yeah, and there’s a line in there said like he who has a why can bear anyhow, you know, it’s a guy that was in a concentration camp like, you know, a psychotherapist, it’s like I address that was living and was just trying to survive and what like when you’re struggling with a substance use disorder It is about survival. I mean it is it is primal, you are just existing and surviving. And then you step into recovery. And it’s it is scary at first and it’s very confusing and it can feel very hopeless. And I think like, having meaning and purpose in your life is what I think is one of the most important things to recovery. And that’s why I think getting back to work, especially for us as physicians, where we’ve invested so much of our lives in doing this and most of us, it’s our identity, it’s who we are. And when you strip that away, which was my experience, which we’ll talk about a little bit, you know that that itself is extremely traumatic and very hard to deal with. And so I think getting back to work quickly, but then once you’re in the workplace, you need support, right? It’s because it’s not, everything’s changed. So you need guidance at work and we need we need systems and people at work in our institutions that we can go to and maybe it’s having groups you know, in the hospital, having you know, a therapist or a peer support individual in the hospital that you can on your break going, Hey, man, you know, I want to talk about this. I want to talk about that. It’s really about like, in essence, it’s about connection and support. Right and believing the people around you are invested in your success. Right. And I think most physicians that are in these physician health programs that I don’t want to totally bash them because there is a lot of good in there. I got and my personal experience was actually very good. But I think it’s a very, it’s a very for most people, it’s a very adversarial relationship. They see it, as you know, us versus them. And it shouldn’t be that relationship has to change, right? People don’t believe they’re there to lift them up and support them and make them successful. their belief is that they’re trying to catch me.
Yeah, they’re there to catch them when they slip up. Not right.
Help them not slip up. Right. Exactly. Which is a huge, like, it sounds like something small, but it’s massive. And it changes the relationship because, like what, like most of us, right, like the administrators, the insurance companies, you know, the PHP, it’s like, it’s this whole constantly, you know, it’s like the whole system is out to get us and we’re working in it just trying to survive and trying to do good. And so I don’t know if I totally answered your question is a great question. And I haven’t thought a lot about that. But
you answered a lot of others. questions that I had along the way?
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

Private Practice Efficiency Matters

On today’s episode we speak to Dr. Phil Boucher, pediatrician, podcaster, physician coach, blogger, and physician efficiency expert. We discuss ways to make sure the private practice physician is maximizing the use of their time. That doesn’t mean no naps! He mentions scheduling nap time into one of his days! The key is to plan as much of your day as possible, schedule in some flex time for unexpected events, and be as proactive as possible about doing your work at times in which you are most efficient – when nobody else is around or awake. Make it happen! This was a great conversation with someone many of you already know from his large online footprint.

Dr. Phil Boucher is a board-certified pediatrician in Lincoln, NE and business consultant. He helps private practice owners design a thriving practice and fulfilling life. Phil is an expert on marketing, branding, and organizational systems specifically for physicians, and his passion is helping tired, overworked private practice physicians climb out of the trenches to work less and earn more. He is the host of private practice matters, which can be found at privatepracticematters.com

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!!!

 

Private Practice Efficiency Matters

On today’s episode we speak to Dr. Phil Boucher, pediatrician, podcaster, physician coach, blogger, and physician efficiency expert. We discuss ways to make sure the private practice physician is maximizing the use of their time. That doesn’t mean no naps! He mentions scheduling nap time into one of his days! The key is to plan as much of your day as possible, schedule in some flex time for unexpected events, and be as proactive as possible about doing your work at times in which you are most efficient – when nobody else is around or awake. Make it happen! This was a great conversation with someone many of you already know from his large online footprint.

Dr. Phil Boucher is a board-certified pediatrician in Lincoln, NE and business consultant. He helps private practice owners design a thriving practice and fulfilling life. Phil is an expert on marketing, branding, and organizational systems specifically for physicians, and his passion is helping tired, overworked private practice physicians climb out of the trenches to work less and earn more. He is the host of private practice matters, which can be found at privatepracticematters.com

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

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

EPISODE TRANSCRIPT

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

On today’s episode we speak to Dr. Phil Boucher, a pediatrician podcaster, physician coach, blogger and physician efficiency expert. We discuss ways to make sure that the private practice physician is maximizing the use of their time. And that doesn’t mean no naps he actually mentioned scheduling naptime into one of his days. The key is to plan as much of your day as possible, scheduling some flex time for unexpected events, and be as proactive as possible about doing your work at times in which you’re most efficient. And that’s usually when nobody else is around or even awake. So you have to just make it happen. This was a great conversation with someone that many of you already know from his large online footprint. Dr. Phil Boucher is a Board Certified pediatrician in Lincoln, Nebraska, and business consultant. He helps private practice owners design a thriving practice and fulfilling life. Phil is an expert on marketing, branding and organizational systems specifically for physicians. And his passion is helping tired overworked private practice physicians climb out of the trenches to work less and earn More. He’s the host of private practice matters, which can be found at private practice matters calm.
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. Phil Boucher. Thanks so much for being on the show today.
Thank you. I’m so excited to be here. I love your podcast. Any physician that has a podcast is extra cool in my book, and you’ve been at it a while and I really like what you have to say and the people that you have on your show.
Thank you. Well, any physician in the podcast space is competition in my book, so no, just kidding. I love I love you. Your podcasts now that you’ve got to So first, just tell us about your your podcasts, and then we’ll get into why I’m having you on the show today.
Sure. So I’ve got two podcasts, I have one, I have two audiences. Basically, I have a parents because I am actually a private practice pediatrician. And that’s my full time job is taking care of little babies and teenagers and everyone in between. And so I have a podcast called parenting matters. That is for parents and it’s all just parenting related topics, sometimes a little bit pediatric medical, but mostly more about the parenting side of things. And I do that podcast weekly and interview lots of I try not to review like a lot of parenting authors that I can get to come on and talk with me about their beliefs about parenting. And then I have a whole other audience which is private practice physicians because I love private practice physicians because they have so much control over their lives over their destiny compared to the employed physicians. And so I love to talk with private practice physicians about how to optimize everything in their life. And in their practice, not just work, not just our views, not just the number of patients seen but optimizing their time, and also the time that they have at home with their family, and helping them to do only the work that they as a physician can do, because I think that’s something that really contributes to burnout is doing a lot of scut work as an attending as the one that’s making all the decisions, but also like waiting on hold to talk to somebody about prior off or physician to physician thing for insurance or filling out FMLA paperwork. So I try and help physicians do what only they can do.
And another thing that contributes to burnout is the loss of autonomy. So the the fact that you’re helping the private practice physicians to remain private practice physicians by optimizing their day and optimizing the practices is going to help prevent and minimize burnout. So that’s that’s fantastic. I love that. Yeah.
Completely because you’re totally right that autonomy is huge, not feeling like you have control over what’s coming up in your schedule this day this week this month this year, contributes to burnout for sure if you just feel like you are beholden to somebody else that’s telling you how to live and practice. And so I do want to help private practice physicians, stay in private practice, be successful, enjoy it and bring other people over to the side of the medical game.
So the reason you’re on the show today is actually to talk about that right your reputation within the physician online community is your that guy who has totally optimized his practice, you have five children, you have a booming pediatric practice, and you have you host to podcasts and and you’re extremely active on the physician online community. So you’ve got all these different hats, yet, you seem to be just the happiest guy in the world. So typically, it’s our practices that are the first things that that really get is down, right that we find frustrating. And we can take that home with us. And, and it’s this looming shadow. And so let’s go through your day, right from the first moment that you walk through the door of your office, to the moment where you leave. How have you optimized your time. So if you want to start with overarching philosophy, or just write today, let’s just get into the meat of it.
Well, I love how you teed that up because I like, do a lot of things. But I literally love like, every minute of my day at work and at home. And I mean, there’s always like the stuff that comes up like I, you know, right before we came on, I was admitting a patient to the hospital of bronchitis and all the different random things come up. But I do feel like I get to do what only I can do and I get to do it as I want and have a lot of control over that, but but it’s taken time to get there. And so when I when I tell other physicians about like how how things worked for me and how it’s been optimized for me, I realized that everyone’s on the journey. And next week, something catastrophic could happen that could totally change that for me. But I’m going to try and help other physicians while I have the time, the energy, the motivation and the love of my practice and get the most out of it. So I appreciate you setting it up that way. When I think about like my day, so I’m kind of a knot, I guess kind of a more traditional sort of physician in that we admit our own patients to the hospital. We see our own newborns in the hospital. And then we have our time in clinic and so like a typical day, I will get up with the kid or get up get the kids off to school I dropped them off usually, and then run to the hospital, see my patients and then come to the office and do my my clinic thing for the day. And then I am able to check out and head home and the kids wake up at about 630 but I can tell you that for both me as a parent at home and as a physician. My day starts way before gametime and so I get up much earlier than my kids. I get my exercise And I do my podcast recording or my social media stuff for the day. So that that’s already done because I enjoy doing that. But it’s hard to find time for it when I’m not just mindlessly scrolling. And then when the kids wake up, I’ve got like breakfast being made so that they can sit down, we can have breakfast, we have a little family, like prayer time in the morning together, and then I get them off to school, and then I go to the hospital, but I don’t just walk in the front door of the hospital and then see what’s on my plate. When I get up in the morning. I also look and see, okay, these are the newborns that I have in the hospital that I need around on, here’s what’s going on with them. I often will do my notes in advance, and either penned them or signed them and then attend them if there’s anything off compared to what I was expecting to find. But for the most part, you know, the patients in the hospital, they’re all newborns and they they they do the same things and epic for everything that’s wrong with Epic, it actually does let you like pull in all the relevant data so I can hit.pb and which is PB newborn, enter my notes done. Ready to sign and it’s got all the important stuff. So I probably am lucky in that I have that at my fingertips while I’m making breakfast so I can record the notes for the day before I’ve even stepped foot in the hospital. And then I can look at them in the elevator on my phone and see when the baby was born, what G’s and peas the mom is anything else going on with a mom, but my notes already ready for me. And so that is that is a big thing that I try and talk to other physicians about is like you got to be prepared if you want to be successful. And so optimizing your day starts the day before or at least hours and hours before you actually set foot in clinic.
right because if you get to the hospital, you’re going to end up chatting with the nurse right half with the other physicians with the and then you could end up in this black hole of socialization which is nice and enjoyable. But then you’ve got to blow through your notes. So if most of that is taken care of in a time when you can focus with no distraction That rats, I feel like that’s the optimization right there.
It totally is. And and it allows me for that I can chitchat with the nurses and ask them about their families and talk with the OBS when I run into them in the doctors lounge or the elevator or the parking garage or whatever, I have that time because I’ve got margin built in because my notes are already done. And all I’m doing is walking around, listening to the baby’s heart, talking to the parents, and then getting on my way to clinic for the day. And those notes, which is like the the only drag of that whole experience. They’re already done before I’ve even walked in the door. And then I can attend them or change them if I need to. If something’s wrong, you know, it’s easy enough to go in and and change them I think even get a little time where it doesn’t even count as an addendum and it’s just editing the note before it’s finalized. But that really helps me to be prepared. I also like sometimes I’ll have procedures that we do. And so I’ll call them and say hey, I’m gonna be there in five minutes, bring the baby back to the nursery. And so we can get those things done. The baby is ready to go. We’re not waiting around. It’s not showing up and then going on. Finding the baby and then finding the nurse. I mean, those are all things that the nursing staff I think, if you talk with them if you’re friendly, if you’re able to have those chitchat and find out about their family, they like that. And they respond to that by being helpful and making your your day go smoothly as well,
that that’s the second time you mentioned that you said ask them about their family. And it reminds me of this recurring skit on Saturday Night Live, where they have someone it’s a game show and the game show is what’s my name, and it’s someone to see, like your doorman or your friend’s fiance, and you’ve met them a ton of time and the question on the show his What’s my name, and your name? So, so if you are engaging with the nursing staff, and not only know their names, but know their significant other and their children and their interests, and you you actively engage them, right, that’s a great referral source right then because everyone’s gonna have Oh, my friends a nurse, I’ll ask her who the best pediatrician is. I’ll ask him Who the best pediatrician is because they’re gonna know. So on top of help you that’s that’s a huge way to get good referrals.
Yes, that is and it’s just like a nice human thing to do to on top of all of that. I mean, in addition to all those other things, it is just nice to do that because then it makes your day fun and it’s nicer to see people and they know what’s going on with you. I mean, my parenting side of my brand. I do Instagram stuff and people, they will ask me stuff that they’ve seen about our kids or I put up a picture of the prime rib that I made for Thanksgiving on Instagram. I can’t tell you how many people have asked me like how did you prepare your prime rib? And just random stuff like that, that adds to that connection and those those moments where you get to spend with them. How did you prepare your prime rib, I did a reverse sear. So 200 degrees for like five hours in the oven, took it out, let it rest and then I blasted it at like 550 for 10 minutes to sear it at the end. It was perfect. So that’s how I did that.
People think that you sear it in order to seal in the juices, which is right, not true. No, it’s trying to formalize the outside to add in a little bit of a different flavor and texture. So
so on that same line. Before we move on from this digression, I will say that you know, you may you put the roast in the pan and like there’s all those drippings and juices that come out. Doing the reverse here. I could have not even put it in a panic. I just set it on the oven. It lost no juice, doing it slow like that at 200 degrees for like four hours. The pan was completely dry, all of them all of the juices remained within.
Amazing, okay, okay. Sorry. That’s okay. You’re inspiring me. Okay. So now you you’ve written your notes on your newborns. I’m assuming now you’re done with your hospital responsibilities.
I’m done with my hospital responsibilities. I’m onto clinic I you like I could call my nurse and find out what’s going on with my patients. What’s coming in the door what’s already waiting for me in the exam rooms but I usually just listen to some music, or have a little mental time in my drive from the hospital, to the office. And I get into the office and I already know you know, I walk in the back door and I can see which rooms of mine I have my rooms are right by the back door and I can see, okay, I’ve got one room to room, three rooms, how many doors are shut? How many patients do I have. But the good thing is, I already looked at my schedule last night. And so I already have an idea of who’s coming in, what they’re coming in for. And then I can go through my day much more easily knowing what’s coming and just like preparing in advance for the hospital preparing in advance for breakfast with the kids. If you take a little time to prepare in advance and know what’s coming in in your day, then it’s so much easier to be successful. You’re you’re running through your day rather than what’s on by scheduled next. What did I just walk into? Why didn’t I read up on what this patient was their specialist said or you know, just being blindsided by those things and playing catch up all day. And so I don’t spend much time doing that but in advance because I know more Patience well, but I at least look and see, okay, this person is coming in, they usually run late, this person usually has extra questions, maybe I’ll block an extra spot for them if I have time, or I’ll try and kind of preempt the visit a little bit. So I know all the different things that are on their minds in advance so that I can talk it through with them. Just taking a few minutes to glance at your schedule for the next day and know what’s coming in. It also helps you know, when you’re talking about the business of medicine, getting people in patients in an orderly fashion and also being accommodating of mom calls in and her child needs stitches, or a dad calls in I think my son broke his arm, something like that comes up, then I can say without having to look too deeply on my schedule. Well, I think I’ll have time at 1030 because those parents are always super quick. They just want the vaccines in the weights and then they’re out. So I can say yeah, break, have them come in at 1030 will take care of their laceration. We’ll get them taken care of it’ll make the patient experience a million times better. I enjoy that stuff and everybody wins. It doesn’t interfere dramatically. With my day or my ability to continue on with my day. It’s not like one thing is going to railroad the entire day and throw it off track because I try and think about margin. Do I have margin to? To add somebody on? Do I need to ask somebody else to do it? Or say no, because I don’t have margin? Or do I have time because I’ve got margin built into my day and into my life, that I can take on these extra things that I can record this podcast episode with you, because I already saw my patients today and, and I blocked my schedule out appropriately in advance because I knew what was coming up. If you plan in advance, it’s so much easier to have that margin that allows you to have control over your life regardless of if you’re an employed or you’re a private practice physician. So you have
that flexibility built into your schedule, right you you. You don’t book your schedule such that you’re filled up to the gills.
Exactly. If I look like I just clicked over to my schedule for tomorrow. I always keep same day six spots open so that if I’m at If some if I’m at a soccer game tonight, or you know, somebody calls me this evening, when I’m on call, and says I need to get in tomorrow, I don’t have to look at my schedule because there’s an 11 o’clock appointments, but time that nobody on my none of my schedulers can book until the same day. So it’s always available. So somebody called me today, and you need to do again, and I said, just coming into 11, we’ll get you taken care of, and then have the staff put that on in the morning. So I don’t forget about it. But having those little built in moments of margin, I know 11 o’clock every day, I’ve got a same day sick appointment that is free. If I’m at the hospital early and I need to have a baby come in the next day. 11 o’clock, I’ve already got a same day six, but at that time, I know it’s going to be open. I know it’s going to be fine for that patient to come in then and I can use that. Or my patients can use that and they’ll feel like they were able to get in quickly with their own doctor, which is a huge patient experience booster.
I actually do the same thing. So I’m in I don’t really talk much about my practice on the show because I’m not really supposed to. I’m writing didn’t build my practice. I’m a partner in it. But I’m part of anti analogy associates, which is one of the, which is the biggest anti practice. Right? Right, right country. And I’m one of the partners so we, we can control our own schedules completely. And so I have same day spots just as you do for one reason is if they don’t get filled, it prevents me from falling behind. Right. Second is, yeah, it gives the patients that one I can tell them, Listen, I need to see you when you’re really like they come in for sinus infections. I’m not sure if they’re sinus connections, they might be migraines, you might be cold. When you’re like, full blown, well, how am I going right? You can get in because if you call that morning, there are spots there inevitably soft spots will be able to get you in and they love that and I love it because then I don’t have to have to kill myself every single day because the robots aren’t always filled. And when they are it’s just a great it’s great for their for their access, which helps me build my reputation with the surrounding referring physicians and with the individual patients. So, yeah, I think building that flexibility in your schedule helps you to minimize your stress and also helps you to build your brand and reputation.
Totally, I agree completely. And those are things to like you said like, if they don’t feel then I just can catch up a little bit. And if I’m feeling a little, like overwhelmed or over busy, then I’ll just block it and then have that time to catch up and look forward to that time to kind of have a little mental break and catch up and have coffee or catch up on my notes or whatever is going on. So that’s kind of how my day operates is I know what’s coming on in advance, I really focus in on making sure that the day is going to go smoothly and having margin built in so that when the inevitable, weird stuff comes up, or the emergency thing comes in, that I’m able to respond to that take good care of patients provide good patient experience, and not put myself in the position to be totally overrun, totally run down by the end of the day and and it takes practice and it takes intention in some days. I’m like, Whoa, that was crazy. We did way too much. Or I think we could go a little bit faster. I try and be careful about like adding a lot of new patient spots. Because sometimes if it’s a slow day, I’m like, Oh, I just need to see more patients but, but I realized that in the grand scheme of things, I am quite busy in my practice, even when I have open spots tomorrow, that that in the grand scheme of things, things are going well and my practice is running smoothly. My patients are getting seen all of those good things are happening.
Yeah, anytime. Anytime. My office hours are slow. I’m like, oh man, my my practice is going in the toilet. What’s going on? And I’m super busy. I’m like, Oh man, I can’t wait for one of those slow days to happen. You know exactly. grass is always greener.
And I make Thursdays today’s Thursday that we’re recording this Thursday’s is my like, ketchup day my nurse and I look forward to Thursdays because Tuesday is a late afternoon and evening clinic. And then Wednesday is a full busy day. And then Thursday I have like two hours. I batch all the patients that are quick, easy. Neither shots need their weights and They’re good to go. So that Thursday, I can have a super quick day and then record podcast episodes, take a nap with my kids that are home in the afternoon. I’ll do all those other things to catch up.
That sounds that sounds fantastic. I could I could use an app with my kids right now. Yeah, totally.
I’m looking forward to it. Then the other thing that I was going to say two is in the exam room, I try and and optimize my time in the exam room with each individual patient to I have never had a patient and I asked frequently, and we asked a lot on text messaging, surveys and everything like that say, He’s too quick. He doesn’t spend enough time with me. Even though I’m busy and I move quickly from room to room I really try and, and prioritize making sure that patients feel like I had all of the time they needed not just enough time for them, but all the time they needed. And so the way that I do that one, I have a scribe so he makes my life infinitely easier, because I’m able to sit and look at the patient, interact with them, talk with them. I’m not saying wait, what did you say? As I’m trying to type and multiple task and multi brain to get the things down in the note that I need to, to respond to messages and all those sorts of things to a patient and interact with them. I’m able to just hone in specifically completely on the patient, what they’re telling me what they need, answer the questions, do the back and forth the way that you were taught in medical school of answering or asking opening ended questions, the onset location, duration, all those things I can just think through as I’m talking rather than feeling like I have to When did it start? type type type? Where does it hurt type type type, you know, doing all that splitting up, I’m able to just completely focus in on what is most important which is getting the history, doing the physical exam, making the plan making the management and my scribe takes care of everything other than me thinking and me talking to the patient and examining them.
So I’ve spoken to other physicians who have used use scribes, and and we both know that your scribe is is listening right now. So we
are here. So I told him, I told Brad before we started that he is my editor of my podcast as well.
So I’ve heard frustration with the fact that you train them and like yours, they leave and go to med school. And they’ve got to start all over again and train another. And so they throw up their hands and say, I’m not doing that, again, I’ll just write the notes myself. What would you say to that person?
I think that one scribes are so easy to train. Because they are. They’re young, they’re, you know, in their 20s. They’re getting ready to go to professional school or whatever they’re going to do. They are computer natives, and we didn’t grow up on computers the way that they did. And so when I have my scribe helped train another scribe in the office, it takes like seven or eight clinical visits, not days, not weeks, visits for them to understand how the system works and all the different things that go into creating the note like they just know how computers work so much better. And then, before they leave, I have them record all of the different screen, they do a screen grab of all the different stuff that they do on a regular basis so that when they move on the person that they train and replace can refer back to those things and say, Okay, how did Boucher always do those quick visits? or How did he put in the ear infection and the ICD coding and the CPT coding all those things? How did that come in? Oh, yeah, I’ll just watch this video and redo that. scribes are great. They want to learn, they want to be helpful. It is not difficult to train a scribe. It takes very, very little time. Now it does take time for them to become pros. But the way that I try and give my self enough time to really create a proscribe is if they’re the ideal person is in that gap year. They’re between undergraduate they’re graduating from medical school or graduating from undergrad, they have a year before they start PA school or med school because they decided to take a year off or they’re trying to beef up their resume or their MCAT or whatever. Those are the ideal people to get first driving They can, they’re usually the right age that they have their parent’s insurance. So they have some insurance. So they’re not expensive to employ. And their schedules are wide open so they can do the different clinic hours that you have. And they’re super eager to learn. And it’s just a great teaching experience, even though grants been with me for two years now, we still you know, he has great questions, and I teach him back and forth. And it’s really valuable, not just for me from a, it makes my day easier. And he does my notes for me sort of place, but also for me as a teaching place, and continuing to learn. And it’s just such an awesome experience that I highly, highly, highly recommend it for anybody that’s having trouble keeping up with their notes, which is every single physician that I have ever talked to.
What about the physicians that talk about the loss of control? And actually, you’ve had a couple episodes on your podcast about a specific issue, right, there’s a I forgot. Dr. Angela, I think referred to the B minus note. Right. Oh, Yeah, yeah, not not all your notes need to be a plus notes. They can be the minus notes and that’s just fine. So yeah, fine. I’m okay with that and grammar and, and punctuation. Fine, don’t don’t go back and spellcheck, but yes. What about the legal liability, the legal liability that you don’t know what they wrote? You think you know what they wrote? But for you to go back and check all of your notes is extremely time consuming. And you just obviated the fact that you have a scribe to begin with, so So how do you how do you justify that? increased liability?
Right? So you’re you’re completely right that at the end of the day, the note falls on you, the liability falls on you. But I think that as you train them and feel more comfortable, the different things that are coming in, you’ll have a different degree of scrutiny depending on the visit. And yes, my well checks I flipped through the plan and and it takes about 10 seconds for me to read through what he says on a note and Make sure that everything looks good before I hit sign off, which saves me a lot of time just typing in the sort of mindless stuff that that you might otherwise that on a note where it’s more serious condition there’s medical legal stuff going on or there’s mood stuff that I want to make sure to capture. I read those out a little bit a little bit more carefully and it does take a little bit more time at the start. Just like when you were learning to type and you did the pack, you know the finding pack or whatever it is, I think you unpack that that took longer but then when you got comfortable with home row and all those things, it did speed up over time once you used home row and got over the initial awkwardness of home row like it’s much faster in the end to do it that way. So there is a little trade off but but in terms of time, the time is so much faster to having a scribe even checking their notes to make sure they that you captured everything that was important. And you develop that trust over time with your scribe that that you feel comfortable with that too. And at the end Of The Day realizing that, yes, there are legal issues and liability issues, the vast majority of notes that you’re going to sign off of, in your long, illustrious career as a physician will go into the black hole of the online cloud or your server. And one or more likely zero people will ever read that note again, maybe when you see them back, you’ll refer back to it, and then it will be filed away forever with no one ever reading it. So I do try and do b minus work on my notes myself, in that I don’t spend so much time on every little point because the likelihood of somebody actually reading that or reading that and then making a political decision or a change in plan because of that. It’s exceedingly low.
sold. I’m sold. I definitely need a scribe so well, my gosh, you do. Where do I find one? So the way that I write the way that I was, yeah, they’re right down right after undergrad right before professional school. Where are they Like I, what I do is we have a local supermarket.
You look young, what do you know,
what, what I do is I have a contact at our local university pre health committee people like there’s people at the university, I mean, at Emory University that helped pre health students to get into their med school, PA, school, dental, school, whatever they’re trying to get into. And those people know all the students and they know who’s doing well. And it’s going to go straight from undergrad into medical school, no chance to be ascribed versus those that want to take some time off or need to beef up the resume or something like that. And then you just make yourself available to them and say, Hey, if you ever have somebody that needs a good clinical experience, or is doing a gap year, please let me know. And they could be my scribe. And I actually have a queue of scribes right now that I literally cannot find someone to take any physicians in my group or any other physician groups around town. Like there are there are scribes that are waiting, so if anyone from Nebraska is little listening to this and once a scribe contact me because I have like four people in my email box right now that are saying, I would love to be a scribe I’m doing a Dampier, Can Can I please be a scribe? And I’m like, I wish I had somebody. I don’t have somebody for you a doctor to pair you up with right now.
So that’s now going to be your new hat, Father, pediatrician podcaster and scribe headhunter.
Right, exactly. I could take on that role too, that that could be a new side gig for 2020. I haven’t decided on that but I will continue to to see if I can make that into more of a side gig I guess. But they do turn over so you do have to kind of just be cognizant of that as you go through and make sure that you are picking people that will likely stay for at least have half year a year 18 months Gosh, anyone that can stay for a year is made in the shade, make them an awesome super scribe and then have them help train the next one.
Okay, so what we’ve gone through so far is at the Getting of your day you do as much as you can, so that you can do it while you’re focused and really in your mind for the rest of the day. This includes patient care and other ancillary responsibilities. That way when you get to the hospital round your time there is optimized when you get to the office, you work in, you create your schedule with some flexible time so that if and expected things happen, you’re able to work them in without, with minimal stress, which helps both you your staff and your patients. And then you’re a huge component of the scribe to help total visits quickly. Is there anything else that you recommend to the listeners that that you’ve recommended? Because I know you’re also a physician coach, right?
Right. So sometimes I do help other physicians that are trying to like get a better time management system in place for themselves or need to work on their social media marketing or something like that. Like I love all that that side of medicine that that really nobody ever taught us in medical school like personal development, how to market ourselves how to be business savvy anything along those lines. The other thing that came to mind when we’re talking about optimizing our day as a physician is when you’re in that exam room and you’re talking with the patient having a good way to move the conversation along. And those are things that you have to practice on an individual person basis. And I’ve talked to, like, I guess, I don’t know what I would call it, watch some other physicians interact with patients, and you kind of configure out a good way to move the conversation along. If one thing that I find that a lot of physicians struggle with is tying up a conversation if the patient has a lot of concerns, or a lot of concerns that we’re not able to actually like address and fix is how to move those things along and tie everything together. So it doesn’t feel like well, the doctor just walked out when when I was still in the middle of the conversation or still explaining myself. I think that’s something that really takes some practice the best things that I’ve found that’s
not an effective way to pivot. Right, right. They okay.
Yeah, exactly. But that’s what I mean. And who would do that, but that’s what people write online is like the doctor just walked out when I was still talking with them. Like, that’s not what actually happens, but that’s how patients perceive it. Yeah, yeah, exactly. And so, two really simple things that I found is if you pare it back with the patient says, so it sounds like what you’re telling me is that your knee has been hurting for the past six weeks, and it all started after a game of soccer where you fell and blah, blah, blah, blah, blah. If you pair it back, it makes people feel understood. And so then they feel like, wow, this doctor listens to me. And that only took, you know, 20 seconds for me to pare it back. But now we’re able to move on to the next part of the conversation, and then move from there rather than letting them feel and go on forever and ever. Sometimes you do have to like rein in the conversation. And the easiest way to do that is to kind of summarize as you Brad just did on this episode, where you said so it sounds like what we’ve talked about so far is these these and these Is there anything else you wanted to talk about? You did that exact same thing and that’s what if you can do that as official It can help to round off the conversation. And the other thing is using follow up follow up is always your friend. And so if it seems like, well, I don’t really think that we have the time to get into that specific issue to the degree that I would like to today. And so what I would like you to do is keep a log of when those symptoms occur, and then I’m going to have you schedule an appointment in a week from now so that we can look at that log and see if we can figure out what’s going on. If you can do that. That’s a great way to end the conversation so that you can move on to the next patient without saying I don’t have time for that problem. Come back and pay me another copay. And then we will go through it at that time. If you can do that and have followed by your friend, then that allows for the patient to feel some empowerment, okay. This doctor cares about my headaches. I need to get more data and more information. So I’m going to keep a log and then I’m going to follow up and then we’re going to talk through those headaches. Well, that just took your visit. That was way over time that you had not allowed enough time for that was given you stress that was making your other patients wait. It made it into something where the patient is empowered. And then we’re able to have another visit where we talk through those things.
I find serving coffee to be an effective way of letting people know that it’s almost time to go and have a coffee machine in your office and just like serve them a cup of coffee, like they know. Okay, that’s this is the end of the meal. It’s time
would you like to see the dessert menu? We’re done here.
Yeah, so so I use dragon eye, right? Because I don’t have a scribe I use dragon. And so when someone gives me their history, what I’ll do is I’ll all parrot it back into dragon and then it writes note. So that really makes the visit move faster, but at the same time, still not nearly as fast as a scribe so totally not know. So I’m still sold on that. Great. Well, this this has been a really great conversation, I think will be very helpful to a lot of people to help them you know, little tidbits that that apply to each person and I’m sure there’s a ton there for for for people. Anything else that you want to mention, before we wrap things up,
I think just the biggest thing is if you can be intentional about it if you can prepare in advance. And if you can say, even if you’re an employed physician, if you can say, Okay, I’m not happy with the way things are going, how can I change those things and then talk with people that can help you. It can be a coach, it can be another physician that’s in the trenches with you, something like that, and figure out how other people are making it work because there’s a lot of innovation that we can have as physicians. But the biggest thing that stands in the way for every physician that I’ve ever talked with or worked with is the way it’s always been done. And we don’t do that because that’s the way it’s always been done, just gets in the way of so much innovation. And it’s not just like doing new cool procedures or new techniques or something like that. It’s literally being able to stay in practice without burning out. And so just because in the past, they did it this way, and they work this many hours and we didn’t have all these luxuries That you young young physicians have and you should be more grateful. That does not mean that that’s how things have to continue. So that’s my little rant or spiel of the way it’s always been done is hardly working for anyone right now. And it’s definitely not going to work as medicine continues to change. So don’t accept that the way it’s always been done is the way it has to continue now or going into next year or the years to come.
My wife and I say that to each other all the time. This is the way it’s always been done is the worst reason to do anything. So Amen. always find always find, find your reason. So where can people find you online?
So I have a Facebook group for private practices sessions. It’s called the private practice accelerator. You can go to private practice dot show, slash join to join that. And I have a podcast called private practice matters. And so that’s where I talk with other experts, like yourself, like other physicians or other leaders in business in industry, to learn how to improve practice. improve the lives of fellow physicians. And those are the two biggest places to find me online.
Fantastic. It’s been a pleasure.
Likewise. Thanks a lot, Brian.
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 a previous guest, or have an idea for a future episode, send a comment on the web page. Also, please be sure to leave a five star review on your preferred podcast platform. We’ll see you next time on the physicians guide to doctoring.
Transcribed by https://otter.ai