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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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
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.
Transcribed by https://otter.ai