Bradley Block

A Panorama of Human Glitches Seen in the Musculoskeletal and Reproductive System with Professor Nathan Lents, PhD

Professor Nathan Lents studied biology at St. Louis University and then completed his PhD at St. Louis University’s school of medicine in Pharmacological and Physiological Sciences.  PhDs need residencies, too, so he did his postdoctoral training in cancer genomics at NYU and loved New York so much that he stayed and is now a Professor at John Jay College in Manhattan and director of the honors program.

His book, Human Errors: A Panorama of Our Glitches, from Pointless Bones to Broken Genes, discusses the beauty of our flaws.  We are not the well-oiled machines that we think we are. This is part three out of three of my interview with Professor Lents. For the orthopods, we discuss how the wrist and ankles developed in such a nonsensical way, and why standing upright causes problems from herniated discs to ACL tears. For the OBs, we discuss reproduction and why infant mortality is so high, our ability to procreate is so inefficient, and if we are already so inefficient, how menopause can actually be advantageous for natural selection.

He maintains the Human Evolution Blog and his podcast is called This World of Humans. He can be found at NathanLents.com

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EPISODE TRANSCRIPT

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Professor Nathan lens studied biology at St. Louis University, and then completed his PhD at St. Louis University School of Medicine, in pharmacological and physiological sciences, PhDs need residences to. So he did his postdoctoral training in cancer genomics at NYU, and love New York so much that he stayed and is now a professor at john Jay College in Manhattan, and the director of the Honors Program, his book human errors, a panorama of our glitches from pointless bones to broken jeans discusses the beauty in our flaws. We are not the well oiled machines that we think we are. This is part three out of three of my interview with Professor lens for the orthopods out there, we discussed how the wrists and ankles developed in such a nonsensical way. I’ve heard him describe it as obnoxious and why standing upright causes problems from herniated discs to all the way to ACL tears. And for the OBS, we discuss reproduction, and why infant mortality is so high. Our ability to procreate is so inefficient. And if we’re already so inefficient, How menopause can actually be advantageous for natural selection. He maintains the human evolution blog and his podcast is called this world of humans. He can be found at Nathan lense.com.
Welcome to the physicians guide to doctoring A Practical Guide for practicing physicians. Dr. Bradley Block interviews experts in and out of medicine to find out everything we should have been learning while we were memorizing Krebs cycle. The ideas expressed on this podcast are those of the interviewer and interviewee and do not represent those of their respective employers.
And now, here’s Dr. Bradley Block.
This episode is brought to you by Orange County bookkeepers, healthcare, accounting, and all in one accounting firm for small healthcare businesses and private medical practices. One thing that I’ve personally love about OCB accountants is that they are quickbook professionals with over 20 years experience focusing specifically on healthcare. They utilize a tailored approach individualized to your needs. They’re a full service bookkeeping firm specializing in accounting, payroll taxes, and financial planning. And for our listeners for limited time, they’re offering 25% off their services for the first three months. You can visit them at OCB med calm that’s OCB m Ed or call at 833-671-3873 or 949215 6200 and check out the show notes for more information. Okay, so we have equal inefficiencies in other other specialties. And I love your description of the human hand. So let’s talk about how evolution has has allowed orthopedic surgeons to thrive As a specialty,
right? Well, I’m more thinking of the wrist. I mean, the wrist seems to me like a really funny arrangement because you have these bones, all these little bones in there, the carpals. And what function Do they really serve separate from one another, the fact that there are seven sort of crammed in there, you know, if you were to design a robot, for example, with a joint, something like our wrist, there’s no way that you would put all of these independent parts together, and they’re mostly fused to each other in the sense that they don’t move relative to one another. So what’s the point? The point is that there is an evolutionary legacy there, and that that arrangement in all of the limbs of our ancestors were it was very similar in terms of the numbers of bone and their relative positions to each other. But we would not design a joint like that today. And in fact, the similarity to our ankle and our wrist, despite them performing almost entirely different jobs, harkens back to that shared ancestral history because our four limit ancestors really did use all their limbs in very similar ways, but we don’t but yet we have that that sort of parallel anatomy and the wrist has weird constraints. I mean, if you try to like twist it around while well bending it, you know, it doesn’t really work nearly as well and the ankles even more rigid. But of course, that’s a good thing. We want a rigid ankle, and we have so much power that we can drive from our, our big toe and so forth. I mean, they really have evolved, well, they just didn’t fix every problem along the way. That’s sort of the theme of
Yeah, if you were to design them de novo, you would not do it this way.
Right? There’s no animal whose anatomy is perfectly designed for how it lives and you could in any engineer could have a field day redesigning the skeleton of almost any creature. But that’s not how evolution works. It doesn’t work with a floor plan, and it certainly doesn’t create new structures de novo, it really takes what’s there and makes tweaks and tugs and even the bones of our middle ear, you know, grew out of brinjal bones previously in our reptile ancestor, so we have to take something and retool it, we don’t really invent new structures. And what that means is you’re stuck With the constraints, because it’s not just that you stuck with what you have, every step of the way has to at least offer a non disadvantage. But really, every step really needs to be advantageous in order to get fully formed something in the future. So you can’t start evolving a structure in the hope that one day it will be useful. That’s just not how evolution works. So if we wanted to grow wings, for example, we’re not just going to sprout new structures out of our back, wouldn’t it be great because then we’d still have our four limbs when they finally got around to being finished. But that’s not how it works, right? You have to, you have to co OPT the anatomy that you already have. So the three times that wings have evolved in vertebrates, all three cases, they lost their four limbs in the process. So birds, pterosaurs, and bats, none of them really can grasp. They can’t, there’s so much functionality with their four limbs that they lost in the process of evolving those into wings. So evolution always just has to work with humanity. that you have. And slight advantage overcomes a slight disadvantage, hopefully. And that’s really, that’s how you get directionality to it.
So it sounds like the wrists and ankles could have been done better, but they’re nonetheless still pretty efficient. Whereas walking upright, seems to be seems to have created a significant hurdle from us because it’s, it’s almost like a domino effect. Right? It doesn’t just affect your back.
Right. I think the back I think our lower back is really the biggest problem with walking up right in terms of sort of incomplete evolution. If you look at the vertebral column of a chimpanzee, for example, or a gorilla, it has this sort of sloping slow sloping bend to it. It’s like a j looks like a capital J, but even a gentle sloping J. And when we wanted to sort of stiff in the back and walk more upright rather than straightening it out. We just introduced another curve. So we have an S shaped back. So we threw this curve into our lower back. And part of that was to accommodate how the organs were going. To attach and to make room, there’s some reasons why it did just straight now, but it did cause a tremendous new point of weakness. And the cartilage in his discs in between each vertebra can now slip out of place much more easily because of that, that bend. So if you can, if you can just picture like a stack of pancakes, but it’s curved, it’s really easy for the little discs of cartilage in between to slip out of place when they’re undergoing strain. And that’s what happened. That’s a herniated disc, a slip disc. And that does not happen in the other apes. It’s never been documented in a chimpanzee or a gorilla to have a slip disc, because their back is optimal for their posture. But our back is sort of, okay. It allows
us to stand upright, but it has a number of weaknesses. So this can also
affect our knees, right?
Yeah, yeah. And I think one of the big problem with our knees is that if you look at how a gorilla or a chimpanzee walks, a lot of times, their legs are bowed and there’s slightly bent and that means That the muscles are doing a lot of work, even just in a resting state. And whereas when we stood upright, we’re now putting the burden of our weight on just two limbs instead of four. And just compensate so that the muscles aren’t doing all this work all the time we straightened our legs. So we stand with a straight leg posture much more often than the other age to, which means that our bones are bearing much more of the weight that our muscles and a lot of, you know, the anatomy evolved to accommodate this, but they’re at least one piece. Well, there’s two that I can think of, but one that definitely didn’t really fully optimize for this is the anterior cruciate ligament, which is right behind your kneecap, and it’s the primary not the only but the primary ligament that holds the upper and the lower leg together. And that’s the ACL as you know. And so anytime you change directions or your your your weight, your momentum changes quickly. If you straighten your leg when you do that, the ACL is bearing the full brunt of That change in momentum, the full force and it just simply isn’t up to the task. It is a very thin ligament compared to the job it’s supposed to do. And it’s not up for because it was in evolutionary lineage, it was that burden was shared by the muscles and four limbs and it was spread more evenly. And now we have this little ligament that’s doing all the work. And there’s no way to get it stronger, through exercise that you can’t like, go to the gym and work out your ACL. There’s just no way to do that. And so what you have to do is hope for the best and try to not let your legs lock when you when you change directions like that. But if you do, and the other problem, of course, is that our athletes are getting larger and larger and larger. If you look at the average weight. Some of these linemen For example, I mean, they’re just massive individuals who are moving way faster than I ever could. And, you know, if they want to change direction quickly, that poor little ACL just snaps
and there’s no way to fix it except for surgery. Evolution keeping our orthopedic surgeons in business.
Oh, definitely. I mean, I’ve had I had surgery myself on my ankle when I was in high school. And it’s one of the things I think about a lot. But if I had been born just 150 years earlier, I’m not talking about Stone Age, I’m talking about 19th century I would have been crippled for life, I would never have walked. Normally again, I had a biomolecular fracture, it had had to be repaired. And simple surgery nowadays. You know, I was in a cat, I was young. So the cast was, I think about eight weeks, and full recovery, full range of motion. You know, I was playing soccer within six months, it’s totally fine. But I would never have walked again. Or at least not normally. Because of that my daughter broke her arm last week. She didn’t need surgery, but it needed to be set. And I just wonder her just just a few hundred years ago, if she would have been a cripple for life, I don’t know. Oh, yeah.
But yeah, I mean, it’s and the amount that our knowledge has increased. Just, it’s incredible. It’s astronomical.
Yeah, I think granted, you know, there’s so much that we’re down about the modern world, and we were talking about dying. And things like this. And we forget that the prehistoric world in some ways we would we were living in better harmonies with our body. But there was really nothing in the way of intervention when
Yeah, if something if something went wrong. Like, yeah, we lived in harmony, fine. But as soon as something goes wrong that
yeah, I think about that with all birth all the time. They’re like, well, women were doing it naturally for millions of years when they were and 80% of the time it went, it went well.
If you’re fine with the 20% mortality,
yeah, that’s that would be good.
Yeah. I don’t think women should give birth in hospitals because it’s required for every birth. I think it’s because the chance of going wrong is high enough that you would really be mad at yourself if you tried to do it at home and something went wrong.
Yeah, it’s it’s nice to have that. Yeah, it goes smoothly most of the time. But when it doesn’t, and it tends to not when things go wrong, they go wrong fast. They go wrong fast. And a quick intervention can save your mom and baby Yes, yeah. So actually let’s let’s talk about that. If you have I’m not sure if you have time, but the OB GYN section of your book, which had a lot of great information in it. So the the inefficiency, let’s just before we get to childbirth, let’s talk about the inefficiency of human reproduction. Right. Yeah, we’re seeing that more and more in the modern world. Why is it so hard? Why do we Why do we have you know that? I feel like every family has a story of difficulty conceiving of miscarriage of stillbirth of like, there’s, there’s you either it’s either happened to you or you know, someone that that has happened to why are we so inefficient at reproduction. It’s remarkable for a lot of ways and people think this is silly to talk about as being inefficient reproducers considering it, there’s like 7 billion of us on the planet now, but can’t remember how recent that population boom really is. And in fact, we were thin on the ground for most of our existence, and in fact, our closest relatives all went extinct. So our success was by no means a foregone conclusion. But anyway, the efficiency is really still, it’s still not every step of the way. Yeah, you’re
right, you’re right. But every step of the way, when it comes to reproduction, we have inefficiencies. And many of them, we don’t even share with our close relatives. So for example, we made sure very late compared to other animals. So we reach reproductive age several years later than the other African apes who have similar lifespans to us. And that creates a lot of inefficiency in terms of evolution, because it’s a lot more chances that you might not live long enough to reproduce. So just that in and of itself is strange and really calls out for an explanation and then how many people have trouble making gametes that are that are viable and successful is really high to now that that rake might not be so different from other animals. But the reasons behind it to me are remarkable. I mean, something like 40% of conception events failed to implant for some reason or another. And I think that 40% is probably an underestimate, but that’s that’s what we do. The best we can do 40% of, of successful sperm and egg union result in a failure to implant. Now a lot of those are chromosomal abnormalities. Others, we just don’t know why failure to implant itself could be the problem. We don’t really know. But there’s just a lot of embryos that just don’t take that aren’t successfully formed or or don’t get the signals out to stop ministration. In enough time, we don’t really know. And that’s why drugs can really tweak this up just a little bit when it comes to the implantation event itself. And that’s just about it. There’s no drugs that help with chromosomal abnormalities, for example. Um, the other thing that’s that’s sort of weird for us is that childbirth is so difficult in humans compared to other species. I mean, if you’ve ever been on a farm, I mean, most of these animals just sort of barely notice when they give birth. It’s it’s really, and and the infants kind of shake themselves off and they’re often on their way. There’s a video you can find on YouTube of a gorilla giving birth and she is Eating, she’s continuing to care for other children. It’s It’s like she barely notices. It’s not a dramatic affair at all. And that’s nothing like what we know, human human mothers experience. And, of course, the obvious explanation is that our, our heads are massive. And so our cranium grew so much over the last, really the last million years, sorry, 2 million years. And it got to this point where we are born too early. That’s really what’s going on. So evolution is pulling on both ends of this road, because a big, big brain is great. It’s good for us. And it allows us to do all kinds of clever things. But it also makes it harder for childbirth. And so this sort of tug of war between the two, the compromise that was made was that we are born at least I would say, two or three months early.
It’s interesting because we, you know, we’ve we’ve three kids, and they refer to the first three months of life as the fourth trimester.
Exactly. That’s the best way to think of it. Yeah,
we were not mixed. Since
Yeah, but if we wait any longer, you know, maternal mortality would be unacceptably high for the species. So that’s sort of the compromise. And it’s not just the big brain. By the way, we also have a fairly narrow pelvis. And that’s because as we transition to upright rocking, we actually narrowed the bottom part of the pelvis in order to so that our legs can go straight down. Because if you watch a chimpanzee walk, for example, they can walk on two legs, but they sort of swing their legs outwards because their their legs go much more out and then down. Whereas our legs go straight down so that we can stride in a smooth way, our center of gravity does not bounce back and forth from the left and the right as we walk. It’s, it’s kind of remarkable. But to really accomplish that you need your legs to be close together. And so but that transition happened two to 3 million years before the expansion of the brain. Right? So those events were not connected. Evolution doesn’t think ahead. So by bringing our legs close together, it was great for walking, but it also put constraints on how big the head could get millions of years. Later. And so when that expansion finally happened, we were fully committed to upright walking. And now we had this big brain. So what was the compromise? We’re just born too early, and our infants are incredibly incapable. Again, if you look at other animals, the infants are much more independent, even in the other eight. Now, the other apes, the nurse, and the babies are, by no means independent. But they’re more successful than our infants are.
Okay, so it’s not just my kids. No, no,
not really. And, and I think you’ll find How old is your oldest three and a half? I think you’ll find he or she is still pretty dependent.
Yes, yes. If we put him out in the wild, he’d be in trouble.
Yeah. And and that’s, that’s sort of the theme of human biology in the sense that our bodies just really cannot make it on their own right. we survive through our cultural status, right? So we help each other we take care of one another, not just kin, but we we take care of one another. We pay people to take care of our kids when we can’t and we solve problems with our brains instead of our bodies and so So the result of that has been a lessening pressure on our bodies to navigate the world on their own. We really are. Our cultural evolution has taken over for biological evolution. And this goes back several million years. I don’t, I don’t just mean since farming. I mean, we’ve been taking care of each other for a very long time. And what that allows is the cultural drive to collect information to have skills that are taught not just learned, but taught. We’re the only species that really teaches everybody, every species learns, but we teach intentionally. And that’s been going on for a long time. And I think that the lesson of that is a happy one. So our bodies are kind of are kind of crappy. But the reason is because we don’t need them to be perfect anymore. We really, we really are solving our problems other ways. So that’s why I like to say the theme of my book is actually pretty happy. It’s pretty uplifting in the sense that aren’t you glad you don’t have to solve the problems with your bodies anymore? Well, I am. I mean, my ankles a perfect, perfect example. Right? This would have been a life altering injury and it’s just not anymore. cultural evolution provided us the tools to fix broken ankles, so that we don’t have to, to try to heal them through, you know, biological means no, we heal them through technological means and, and like my vision was terrible, absolutely terrible part of that is the way we live. Now. We can talk about that if you want, but I had like 2450, and I had these minus 4.5 lenses. But with the advance of this book, I paid a surgeon to shoot lasers in my eyes. And now I see perfectly so. And we just keep solving all of the deficits of our bodies by using our brains or other people’s brains. And I think that’s a good thing.
So another thing that you that you discussed in that reproduction section section of your book is the C section. And I thought that was really interesting that the C section is is just much much older than I than I ever thought it was.
Yeah, yeah. I think that people have been slicing into mothers in distress for a long time, and I think it’s So there were, you know, ancient Roman tales of it. And part of the there was, you know, of course lore about it and supernatural beliefs about this than the other and it became a public health policy around these fetuses and so forth. But I think there was a long been the recognition that particularly during breech delivery, which you can, you can feel you can you can tell when a baby’s in the breech position, that the success rate of just a regular vaginal delivery was so low, that it was worth the risk of opening up her abdomen, knowing that she probably wasn’t going to make it but the baby could, and the baby probably would, in that case, and then with the mother, you so we’re up and hope for the best. But I mean, it’s called the Syrian for a reason. It really does. I don’t think that Julius Caesar was delivered that way, but it does go back to Roman times. And it’s also been documented in other cultures as well, because it’s not rocket science in the sense that you sense through your feeling you through your hands, excuse me, your tactile senses that this baby is not in the right position and every other time that happened, you know, it’s been unsuccessful and we lose both what, you know, what else do we have? What else can we do with the tools around but get a sharp stone and do our best, then that learning and teaching in that institutional memory? Exactly. You have the knowledge and it passes on and but the idea that a woman would die in childbirth was also not altogether, you know, unusual. That would have been, you know, just part of the expectations that at a certain number of women don’t survive. And so well, she might not make it anyway, we might be able to save the baby let slicer open and hope for the best. And so I think that that practice, I think it’s overdone. Now, I think you’d probably agree that we probably do a little, little too many of them. I also am not a big fan of induction, but we can that might be a conversation for another day. But the point here is that it is an ancient practice and it’s worked and it’s been in response to the fact that we have this huge head.
Yeah, I’d rather not just lacking any expertise in in that area. I definitely am not going to criticize my ob GYN colleagues with with regards to the frequency of the C section or induction because they’re they’re definitely working with much, much more information much more than institutional memory.
But you and I have aware that our the infant mortality rates in the United States are the highest in the industrialized world. I mean, we’re Yeah, yeah. And so it’s some combination of factors. And I don’t blame the doctors at all. I actually blame a lot of the legal culture around health care in this country for a fair number of for amount of it. But I do agree with you in the sense that we don’t have the information we need to really know what’s going on there.
Well, there’s also, you know, there, it’s higher in some populations than others. So it’s much higher in African American women, then it is in white women. So there there, there are a lot of factors at play here.
Then, yeah, I mean, the tragedy in this country is that that we do treat populations differently. And some of that provides for a natural experiment. But the problem is, there’s so many confounding variables, and unfortunately, in this country, race and wealth are so tied, that you can’t know You know what’s at play in those cases? I mean, you really have to bear down in the data to separate socioeconomic status from race. And, and but we do have the natural experiment of if we just consider wealthier populations and compare them to say, Canada and other UK with otherwise culturally similar populations. And we just don’t see the rate of infant mortality that we see in the United States. So something’s going on.
Yeah, I definitely don’t disagree with that. There. Were there were two more parts. Before I let you go. There were two more parts of the book that I think bear mentioning and and when we were talking earlier about the inefficiency of human reproduction, and one part that plays into that is hidden estrus? Yeah, right. I don’t know when my wife is. And neither. Neither she so I mean, we have an app now. Right? Yeah. So that can that can be pre app. Right? You just, you know, yeah. Well, there’s no you had to just you had to just keep trying, even though that adds the inefficiency. So what would be the advantage?
Well, it’s a great, it’s a great conversation because we really are unusual in our hidden population. I mean, if you when a chimpanzee is in heat, you know, it is visibly conspicuous. She knows, everybody knows. And that’s how it is with with other mammals is population is advertised and in humans it is hidden even from the woman herself. And there’s a lot of theories about this but the one that I think holds the most water is that it represented this transition to this group living communal living. And it was a trick that women’s bodies played on themselves in men to create a family to to get a man for, for example, to stick around and to protect his investment and to no BS be assured of his paternity and it was also her way to make sure that she got parental investment out of him. So they were both sort of playing. It’s sort of this battle of the sexes and a lot of people would say That the the concealed population was sort of the first step in that in creating a nuclear family where the reproductive interests were there only aligned if you’re if no one’s Sure. And so you had a lot of sex you had a frequently, that was the only way. And it was essentially mate guarding in a sense, but it was made guarding in a way that the female has a lot more agency over the process. And I think that’s where hidden estrus came from is this idea of keeping men interested in sticking around and and protecting their reproductive investment and then also from the female point of view, getting some parental investment out of dad, by allowing him to ensure that it’s his biological offspring that he’d be investing into. So it was them sort of finding a way to align their reproductive interests, and I say finding away meaning none of this was intentional or conscious. Yes, sir. Yeah, and it corresponds well with menopause as well. So from the best we can tell menopause kind of came about sort of right around the same time and what menopause does Is it stops reproduction before the end of the lifespan, which is very unusual. all mammals, with a couple of exceptions, reproduce all the way through their lifespan, a female can can reproduce in, you know, all the way. Yeah. And humans can’t they stop at some point. And that was always unusual. You will see this presented in a weird way. Like, why is she still alive if she’s not reproductively capable, which is, besides being horribly misogynistic, it’s also framing it backwards. It’s not that she continues to live after she runs out of eggs or whatever, it’s that she purposely shuts down reproduction even though she has like lots of life left.
Why did she stop white right, he’s able to reproduce not why she’s still alive.
And thankfully, we’ve now discovered an inch into two species of whales, the pilot whales and the killer whales. And which, why I say this is great is that we can allow we can study them, and we can see how it works in those species. And we can extrapolate so the idea is, what it what it reduces is what we call intergenerational conflict. So when mothers and grandmothers are both reproducing at the same time, their children and it will be siblings versus aunts and all that start competing with each other for attention, for resources and for investment. And so to have, from a grandmother’s point of view, there’s nothing to be gained by continuing to have more children that will just simply compete with her for her children and her children’s children for limited resources. So instead, her better reproductive strategy is actually to stop reproducing herself and invest all of her resources in her children and her children’s children so that they can compete against other grandmother’s children. So it’s sometimes called the grandmother hypothesis. But it’s not just about conflict parties is what a lot of people miss about this. It’s not just about Oh, grandma’s can spoil their children and their grandchild, they could do that anyway. But the reason the real thing that they’re trying to avoid is intergenerational conflict, because for her it becomes a zero sum game to have her children outcompete her grandchildren or vice versa. You know, either way, but she’s so if she could Invest in their success another way, and it frees her up to do that. And remember, it doesn’t matter these grandmothers also have are older by definition. So they have more cultural wisdom, they have more cultural knowledge to share. They are a commodity a precious resource, and so that what they are passing on to their children isn’t necessarily food, literally food, it’s the knowledge of where to find food, how to prepare food and all of that. So it is valuable.
It doesn’t make sense for her to have a two year old when her daughter or son has a two year old because then those two year olds are going to be competing with each other and that’s what she said, is a zero sum game. So it’s better for her to give more advantage to her grandchild two year old than to have her you know next.
That’s right. That’s right. And the powerful evidence for this has been found in these killer whales. So if you look at pods of killer whales, for the most part, they are families and they are led by older menopausal females because they know where the seals are. they’ve they’ve fished those routes, for jet for decades and they have all the wisdom and the knowledge and that’s that’s a good lesson for us. You know we should be we should be electing grandmothers to our, to our highest office in the land, although we had a chance to do that we had an opportunity. But it just shows that that actually care for elders really is a cultural phenomenon that was born out of their value, their wisdom, they’re not they just know more because they’ve been around. And it’s not just women, women seem to be more generous with their wisdom and knowledge. But we we have fossil evidence of older men really, really old men going all the way to humble Erectus that could not possibly have been physically fit. They must have been a burden on the group physically, but they were kept around and they were aided people chew their food for them and so forth, because they knew things. And that was valuable to the group. So that’s another I think uplifting story in my book is that freeing us from just our bodies being well, it also allows us to live longer, in a happy way in a productive way. You can contribute long after Your body has seen its best days and that’s that’s what that’s what being human is fantastic.
Well I really appreciate you coming on the show a second time. My pleasure I love a human errors a panorama of our glitches from pointless bones to broken genes. really a fantastic read. I really recommend it to all physicians. Well, everybody, but certainly physicians because it really gives us a lot of great perspective like what we talked about today on on how we ended up where we are and and when you’re doing especially if you’re doing a surgery, right everything just kind of makes a bit more sense when when you’re looking at through this lens. So I really appreciate your taking your time.
Thanks for the kind words is my pleasure.
That was Dr. Bradley Block at the physicians guide to doctoring. He can be found at physicians guide to doctoring calm, or wherever you get your podcasts. If you have a question for previous guests, or have an idea for a future episode, send a comment on the webpage. Also, please be sure to leave a five star review on your preferred podcast bye form. We’ll see you next time on the physicians guide to doctoring.
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A Panorama of Human Glitches Seen in Otolaryngology and Nutrition with Professor Nathan Lents, PhD

Professor Nathan Lents studied biology at St. Louis University and then completed his PhD at St. Louis University’s school of medicine in Pharmacological and Physiological Sciences.  PhDs need residencies, too, so he did his postdoctoral training in cancer genomics at NYU and loved New York so much that he stayed and is now a Professor at John Jay College in Manhattan and director of the honors program.

His book, Human Errors: A Panorama of Our Glitches, from Pointless Bones to Broken Genes, discusses the beauty of our flaws.  We are not the well-oiled machines that we think we are.  This is part two out of three of my interview with Professor Lents. In this episode, we talk about how anthropologists have actually informed our current knowledge of nutritional science from the perspective of “how were we designed to eat?” We then get into the weeds with a few medical specialties. For the ENTs, we discuss how the recurrent laryngeal ended up in the chest, why humans are the only primates who choke on their food, and what the heck do the sinuses really do?

He maintains the Human Evolution Blog and his podcast is called This World of Humans. He can be found at NathanLents.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!!!

 

This episode is brought to you by Orange County Bookkeepers (OCB) Healthcare Accounting: an all in one accounting firm for small healthcare businesses and private medical practices. One thing that I personally love about OCB Accountants, is that they are QuickBook professionals with over 20 years’ experience, focusing specifically on healthcare. They utilize a tailored approach individualized to your needs. They are a full-service bookkeeping firm specializing in accounting, payroll, taxes and financial planning. For our listeners, for a limited time, they are offering 25% off their services for the first 3 months. You can visit them at OCBmed.com or call 833-671-3873 or 949-215-6200.

 

EPISODE TRANSCRIPT

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Professor Nathan Lenz study biology at the St. Louis University and then completed his PhD at St. Louis University School of Medicine, in pharmacological and physiological sciences, now PhDs need residency to so he did his postdoctoral training in cancer genomics at NYU, and love New York so much that he stayed. And he’s now a professor at john Jay College in Manhattan, and the director of the Honors Program, his book human errors, a panorama of our glitches, from pointless bones to broken jeans discusses the beauty of our flaws. We are not the well oiled machines that we think we are. This is part two out of three of my interview with Professor lens. In this episode, we talk about how anthropologists have actually informed our current knowledge of nutritional sciences from the perspective of how are we designed to eat. We then get into the weeds with a few medical specialties. We start with EMT In this episode, something near and dear to my heart, and we discussed how the recurrent laryngeal nerve ended up in the chest. why humans are the only primates who choke on their food. What the heck does scientists really do? It maintains the human evolution blog. This podcast is called this world of humans. He can be found at Nathan lense 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 Krebs cycle. The ideas expressed on this podcast are those of the interviewer and interviewee and do not represent those of their respective employers.
And now, here’s Dr. Bradley Block.
This episode is brought to you by Orange County bookkeepers, healthcare, accounting, and all in one accounting firm for small healthcare businesses and private medical practices. One thing that I personally love about OCB accountants They are quickbook professionals with over 20 years experience focusing specifically on healthcare. The utilize a tailored approach individualized to your needs. There are a full service bookkeeping firm specializing in accounting, payroll taxes, and financial planning. And for our listeners for limited time, they’re offering 25% off their services for the first three months. You can visit them at OCB med calm. That’s OCB m Ed, or call at 833-671-3873 or 949 to one 560 200 and check out the show notes for more information. Dr. Nathan Lance, thanks so much for being on the show again.
It is my pleasure.
So how have the anthropologists driven our current knowledge of nutritional science?
That’s a great question because I think a lot of the public gets a little frustrated by every five or 10 years. We’re told a different diet is the way to eat and minimize this and maximize that and I think suddenly reached clarity by trying to answer the question of what were we eating as we evolved as our metabolism evolved, and I don’t mean over a few thousand years, but over millions of years, and the anthropologist the evolutionary anthropologists have have made a lot of progress and understanding what we ate, really, as we transitioned out of the rainforest into the grasslands, and became, you know, omnivorous opportunistic feeders. And what they’ve really shown us is that the vast majority of the world’s cuisine right now, every, every culture that you go to the main staple food is carbohydrates, and they put other things on top of that, but we are getting something like 70 to 80% of our calories from carbohydrates. And that just wasn’t the case. For millions of years of our history, carbohydrates were always there, but they were a much smaller percentage of our total calories. And so what we find in a carb hydrate based diet is that the blood sugar swings a lot more. So you get spikes in blood sugar, which are also followed by troughs, because the insulin response gets exaggerated. And so you have this really up and down blood sugar insulin reaction after every meal instead of a more of a slow roll. And the advantage of the slow roll is number one, you don’t get hungry between meals as much you can go long periods without eating without being consumed by that hunger. And then also Most importantly, the way that it affects the energy metabolism of the excess calories that you have after a meal. So a slow roll of glucose and insulin actually promotes this the temporary shortage storage of calories in the form of carbohydrates, glycogen and so forth. But a spike promotes long term deposition of calories in the form of fat. So paradoxically, a high carbohydrate diet is a good way to get fat and a high fat diet is not the It seems paradoxical. But you know, these these molecules are all inter converted into one another. So you can eat carbs, and it gets turned into fat by your body. But I think the anthropologist really led the way by looking how we evolved and how hunter gatherers eat now. And it was really the invention of farming that produced all these carbohydrates as a key part of our diet.
I guess they were much harder to come by previously. And also you were able to mass produce them and refine them.
Yes, yes, exactly. The mass production in the form of farming is what allowed it because carbohydrates are always there, we ate tubers and routes, but imagine, you know, all the digging that you have to do to get, you know, one route that you then usually have to cook and you know, it’s just not going to be a big part of everyone’s diet. And sugars, especially, you know, would have been great when they were found here and there, but it would have they would have been sprinkled through our diet. Whereas nowadays, the amount of sugar that you can eat in one big breakfast can be more than hunter gatherers eaten in several weeks.
Well also even if it is sugar, like it’s If sugar in the form of an apple, the Apple has fiber in it, fiber slows gastric emptying. And fat does the same thing they slow gastric emptying. So that’s that slow roll that you’re talking about.
Exactly. And so one way you can, if you have a lot of sugar, just minimize how much it is per meal and fill it with other things that can help but it really just just the total amount of sugar in an apple. Well, also you have to realize the apples we eat now are not like the apples. We were eating. For most of our history, right? cultivation has made them big, rich and much more sweet. So the amount of sugar that we previously got from apples was much less also. Yeah, but my apples
have a little sign on them that says non GMO.
Yeah, you know, they’re modified. There’s almost no food in the supermarket now that hasn’t been genetically modified through not through artificial selection. So we selected apples to be very big, very sweet. The original apples would have been more closer to the size of a large cherry and not near as sweet, much more mealy and fibrous and I don’t think almost any of the food that we evolved eating would be very palatable to us now.
Yeah. So is that what you’re saying is are you saying we should be eating roots and grubs?
No, I’m not actually I think you can eat a modern diet that is better balanced in terms of the of the macromolecules. So, you know, what I eat a lot of is nuts. I eat a lot of nuts, especially for lunch. And I tend tend to reduce meat for environmental reasons. I do think meat is a healthier way to eat, but I can’t justify it right now in terms of just for environmental reasons. So I try to substitute with nuts, that’s what I think is is you get a lot of fat, a lot of protein. And I can have two pieces of fruit, and a couple handfuls of nuts for lunch, and it’s really um, good until dinner. Now I’m hungry at dinnertime. Don’t get me wrong, but I think it’s a healthier way to eat and I don’t get those spikes and insulin that cause you to become ravenously hungry in between meal to use modern nomenclature that would be hangry. Behind grades hecklers, right? And I also don’t get tired. I don’t need a nap during the day either because that’s another thing. That the sugar and insulin spikes will do to you is just zap your your energy.
Yeah, when I was a medical student it just baffled me that after lecture I would go to Wegmans get a big sub that had all this white bread on it. And and then I’d be so tired I’d have to say I was useless. I couldn’t study I’d fall asleep it was and I had no idea that you know, the cause and effect was right in front of me but I but I had no idea. Yeah, now it’s you know, now it’s become a now I’m so attuned to that. Like, I only the only time I’ll have something that’s that’s carb rich is when I know I’m going to bed soon just because I’m so like, I can’t have something like that and then go on to start seeing patients just doesn’t work.
It is good for falling asleep. That’s true.
Yes. Then Thanksgiving everyone says, Oh, it’s the tryptophan. Yeah, definitely. No, it’s because ones and we get a big sugar spike, followed by the insulin spike and then we’re and we’re storing fat.
Okay, yeah, no and Thanksgiving dinner that yeah, it’s not the turkey. It’s the stuffing.
It’s the it’s the I think it’s the stuffing stuffing yourself. Yeah, exactly. We’re stuffed. So is there any other tidbits that you have for our physician audience here about what we are about a current status of nutritional science based on how we’ve evolved?
Yeah, well, I would say that to throw away any of the hard rules, there’s no there’s no need for three meals a day. There’s no need for getting enough carbs or anything like that. The key thing I say is to minimize carbs, maximize proteins and fats and then also and this is the key one is listen to your body. Try different things like for me breakfast just doesn’t work. But there are some people who who are eat a very healthy diet and breakfast as part of it. So if you can’t do away with breakfast, then just find a healthy breakfast to eat. That’s protein and fat and not carbide for me, no breakfast is works well for me. So listen to your body and follow the cues and give any diet a little bit of time to work it as you reduce carbohydrates, you’re not going to like it at first. Giving up lunch, for example is very hard for me to do but once I’ve done Now I can do it any, any day I want. I can’t usually do it two days in a row, but I
just listen to your body. That’s I would say, and I think not being dogmatic. That’s one of the issues that I have, like the Paleo diet or the keto diet is that, you know, in order to stay in ketosis, just the, the mental energy that it takes to do something like that, I mean, if you’re a high performance athlete, and you’re like trying this for a reason, but like, I don’t know, to recommend that to your to patients, that’s just completely overhauling.
Yeah, I ended up living, then that’s not evolutionarily correct, either. Because we were very opportunistic. We did sometimes feast we did sometimes eat, you know, the rare foods and we got a windfall of this, that or the other, that’s okay. It’s all okay. With that saying everything in moderation, including moderation. It’s okay. I mean, I have dessert every now and then I love pizza. You know, you just have to work it into regular routine of healthy of healthy foods.
In New York, how can you avoid pizza?
Yeah. wouldn’t wouldn’t dream of giving a pizza.
Alright, so let’s let’s move on to the different specialty sections of your of your book. So one thing that’s near and dear to my heart otolaryngology. You mentioned the recurrent laryngeal nerve. And I thought that was really entertaining because, you know, we do thyroidectomy is and so when you’re doing a thyroid, when you’re removing a thyroid, you have to find the recurrent laryngeal nerve. And, you know, you’re explaining it to a patient before surgery about how this is a risk. And it never made sense that it ended up just getting hooked under and coming back up. And, and I think of like, you know, in the book you brought up what it would look like in a draft or a Brontosaurus, right, right. Like, it’s just that nerve is gonna be so long in that animal. Yeah, but so how did it end up that way?
Well, so the nerve makes a pass from the brain to the lyrics to the voicebox and its earliest incarnation, you gotta remember that these These cranial nerves these are ancient ancient nerves, the spinal nerves and cranial nerves go back way back in our evolutionary history. And so if you go back to the earliest incarnation of this recurrent laryngeal nerve, it made a shot from the it was in fish, we’re talking about fish here. So the shot that the drive that it took to go from the brain to the gills because our larynx evolved from the gills, and that was this nice straight shot very short. And they didn’t, they didn’t, they don’t have a neck or a chest, fish don’t and so as our heart and they do have a closed circulatory system, they do have a heart. And as the heart migrated away from the brain, in the development of tetrapods, you know, infamy, reptiles, amphibians and so forth. You sort of elongated and created a true neck, a true chest that’s separate from the head, so the heart and the brain started to become separate from one another. Well, this nerve sort of meanders through the vessels of the heart, even in fish, but it makes us Rate shot. But as the heart moved backwards, or I should say downwards, if we’re talking anatomical position, in the more inferior position, it brought that nerve with it because that nerve gets tangled around the aorta, the aortic arch. And so developmentally, if you think about tweaking genes with random mutations, it was just too much of an ask to untangle that using random mutations. And so the solution that not a solution, just what happened was that the nerve just got pulled into the chest. And so this nerve goes from the brain loops around the aorta. Because it exits the vagus nerve. It’s in the Vegas nerve bundle in the spinal cord, and then it comes out in the chest and then comes back up to the neck. You know, the other nerves in our neck don’t do that. This was the only one that there was just just bad luck. And it didn’t, it didn’t sort it out. But as far as we know, every vertebra it has this problem. Every single one, every single tetrapod, every reptile, every mammal so and we’ve dissected The giraffe and you can see this, this several meters long nerve that could be measured in centimeters. It’s measured in meters in the giraffe, and so we would assume no one’s ever fossilized. We’ve never seen a fossilized version of this and the Brontosaurus and you know the other bracket. So the bracket soars the other but dinosaurs in that family, but we would have just assumed by extrapolation that they would have this several meters long at that point, probably double digit meters long, recurrent laryngeal, it doesn’t cause problems day to day. But what it does causes that as you mentioned, neck surgery, but also chest surgery. cardiothoracic surgeons have to look out for that nerve as well. Because if they accidentally cut it, while performing a bypass or anything else, the person will learn to will need to learn to talk again and potentially I’m actually not entirely sure how permanently disabled you are without that nerve. That’s something you would know I imagine.
Yes, yeah, that’s this is something this is something of a treat. So So ultimately, what happens if the nerve does get cut than half of the cord you know, that cord doesn’t move Right. And so what generally happens is it becomes fixed in a medial position, so that you bring one you can bring your other chord over to the other and then you can have a voice. But for a while you just have a very breathy voice because your vocal cords don’t close. Mm hmm. Which means you have to take a breath between almost every word that you can be at slightly higher aspiration risk, because purpose the larynx is the valve to prevent aspiration. Mm hmm. But, and then one of the surgeries that we can do, we can actually put some filler into the cord, if it’s not getting MIDI alized to in order to force it to towards the middle so that the other half so that the valve becomes competent again, and you can create a voice and you can prevent aspiration. We put like, similar to what you would use to get rid of someone’s wrinkles, like Breslin, and then you know, and then there’s more permanent surgery if you’re finding that that the paralysis because it was cut rather than just stretched and poetic. So that’s, that’s how we that’s how we manage a vocal cord process. So, so speaking of which, speaking of the valve, the larynx being a valve to prevent aspiration.
I was just gonna say that
is choking risk.
Right? Right. Really the elephant in the room when you’re talking about anything going on in the neck is that the common tube for food in the air? You know what could go wrong, the aspiration risk that humans face is actually greater than most of our relatives, especially in early childhood. I mean, choking is a is a hazard as an extreme hazard in our species. And it’s because our throat is so shallow, it’s really shallow. And so you have in a very small amount of space, you have a lot of work to do to make sure that the food gets into the right place and the water especially in the lungs, don’t take that on. And just just the fact that we have a throat where the food and air start off on the same path is really an unfortunate design. And there’s there’s a lot of downside to it. And in fact, if you look at birds, for example, whose whose nostrils make a direct shot to their lungs, bypassing the throat all together, thank you Have it so much better than we do and snakes as well. So birds and reptiles, most of them actually have a separate conveyance of air from their nostrils. So if you see a snake that’s halfway through swallowing something, you’re not like, Oh my gosh, how is he possibly breathing, he’s breathing just fine and so are the birds too. I’ve seen a bird with a fish sort of stuck in its throat. And while it needs to, it does need to get that fish up or down. It’s not going to fix he ate it while it’s figuring that out. And so in fact, I saw this one bird on the beach one time I was watching and he made about five or six tries to swallow this fish wetting it in the saltwater and trying everything each attempt took several minutes and eventually gave up he couldn’t couldn’t swallow this fish. straightaway. Yeah, very frustrating, but he wasn’t. It’s fixed at you know, he had no trouble breathing while he was trying to do that. And there was no urgency as
if I don’t swallow this. Yeah, I’m gonna die.
Yeah, right. Right. So we don’t we have that problem where we can easily get food lodged and if it gets lodged in our throat, the nasal pharynx joins, as well of course so there’s no the nostrils are Any help if you’re if you’re stuck in your throat, so that’s that in of itself is poor design. But the other apes share that design with us and as all mammals do, but the other apes have much more room to sort the flow of traffic into two lanes, so to speak. So the epiglottis has more room to do its work in covering the glottis. But we don’t so what happened was that our larynx migrated upwards over the last really, fairly recently, the last couple hundred thousand years, maybe a million years, it migrated upward. Now that migration is measured in millimeters, not maybe centimeters, but at the same time, there’s just not a lot of room back in the throat anyway. So that was precious room. And our babies, as we know are born quite incapable. And so choking is just a major hazard that really has to do with the anatomical design of the throat.
And actually when you’re born, your larynx is much higher. Mm hmm. I see. I see a lot of patients newborns come in with learning Malaysia which is this is just a floppy larynx. So their larynx makes a lot of noise when they’re breathing. And so they come in, and the parents often complain that their kid is congested. Because it sounds like it’s coming from the nose. And the reason it sounds like it’s coming from those because the larynx sits so high and the reason is because they you know, if you’ve ever tried drinking while you’re lying on your back, doesn’t work if you’re gonna aspirate, but they do they drink lying on their back all the time. And they do, and they do just fine. And I think that’s the reason that the larynx needs to be so high initially and then and then it just ends. So is the reason that it ended up elevated in us is that because it’s a more finely tuned communication apparatus, and that’s why it needed to be higher.
That’s certainly the the thinking, you know, it’s one of these things in evolution where you have an explanation that seems to fit all the data but you can’t know for sure without a time machine exactly what was going on, in terms of the selective pressure, but what we do know is that having a larynx that’s higher in our throat allows us to make a much richer variety of vowel sounds and so Certainly none of the other apes, but most of the other hominins. As we model what their throat look like, they wouldn’t have been capable of the kind of speech that we can make. So the fricatives and the other sounds that are made by the puckering of your soft palate and your throat. And certainly the click sounds of some of the earliest spoken languages are simply just not possible without that larynx being very, very high. And so and the reason why is that you shape your throat right before the air gets to the larynx. And then you have that you just have a lot more in your toolkit. And so most of Neanderthals had this fairly high throat as well. So some people infer that they must have been able to speak because we can’t think of any other advantage for that high voicebox clearly disadvantage, and otherwise, it’s a disadvantage. Yeah, we understand all the costs, but the only benefit we can, we can see is in speech. And there’s disagreements about that too, because a lot of people think that actually gestural communication probably drove language. I don’t see those as either or I think gestures were a big part of our communication toolkit. We’ve transitioned more towards vocal auditory communication in the last million or so years. And I think that was when the fossil record supports the idea of the the throat migrating upwards and upwards. Particularly the hyoid bone is, is generally the easiest way to do this because larynx doesn’t fossilize as well, really, at all. But the hyoid bone does. And so these are inferences that are drawn from the position of the high end form in the throat.
Yeah, the hyoid bones. Interesting because we, we remove it with impunity,
right? It’s one of the few bones that’s really not attached to any other bones, right? It’s the scaffold for the musculature involving the larynx as I understand it,
but but even like if someone has a third gospel duck cyst, which is you know, the third starts off in the back of the tongue and then it extends, it descends to below the larynx. It sometimes leaves a little bit of trail of what becomes a cyst behind that then needs to be removed and in removed, so we remove the hyoid bone with the cyst, and it greatly decreases the recurrence risk. It’s called the SIS trunk procedure
and can they speak more Totally fine. Totally. And I wonder, though if that if that’s because they’ve had the benefit of proper development up to that point. So if you would remove the hyoid bone at birth or in utero, probably not as much, or what do you think? Yeah,
that’s that’s an interesting question is your question that will never be answered?
Well, I mean, yeah, I mean, you could do you could think about experimental ways to do it. Not on humans. But yeah, you’re right. It wouldn’t give you quite the developmental question we’re asking.
So yeah, the, as far as we don’t know, what it’s what its value is there’s, you know, it’s interesting, we learn these things. And now talking to you, especially with your with your book, it turns out that the answers that we’re sometimes given are just based in conjecture, not based in evolutionary development. Like, you know, I learned that the hyoid bone developed and really it only seems to function in roaring in lions, and so it doesn’t, it doesn’t have a role, but but it did have a role and then maybe, maybe it doesn’t any longer. Maybe it says, in development, but not then. Once you’re developed, and the same thing with, with the sinuses, right, that’s, that’s something that you and I have been communicating about trying to try to figure out because what we learn is, well, it could be to help Rhett increase the resonance of your voice, or it could be to lighten your skull. Or it could be to a crumple zone. Like if you’re, if you’re a primate swinging from a tree, and you smash into a tree and you break your sinuses, you, you know, it functions like a crumple zone, so you don’t die. And maybe you can go on to reproduce, although, probably not likely.
Yeah, I mean, I would be skeptical of all of those explanations and not again, not that I think they’re, you know, terrible stories, but it’s just hard to see selection at work in cases like that. But what’s interesting about medicine and evolutionary biology is they both have this tendency practitioners like like, like yourself and myself, of creating stories that fit the data. And usually these are just fanciful stories, but actually, when met In an evolutionary biology come together there. And they, I think the stories that they tell together actually tend to be much more accurate than either one does separately, because evolutionary biologists think about selection. And they think about ancestral environment. And physicians think about how the body works right now. And I think when you put those two perspectives together, especially if you have a good background in anatomy, I think is when you really, really get insights in how the body works. And to me, the hero of all this is Dan Lieberman, if you know him at Harvard, he really approaches the anatomy of the human person from an evolutionary perspective, and it’s really insightful.
Yeah, it just it gives us this completely different perspective rather than having to make up a story de novo of where this why this exists. You know, if you talk to an evolutionary biologist about it, you’ll get a lot more insight and and do you want to go into the sinuses a little more we can save that for article
because I think it’s a good it’s a good example of how just because something does something for us now doesn’t mean that that’s what it was evolved. To do for example, or that it gave enough benefit to a really been considered an adaptation. So yeah, let’s talk about the science.
So as far as what they do now, it seems like they do nothing, right. What they do is they they secrete mucus, which then gets pushed in a very specific direction actually against gravity and for some of the sinuses, into the nose, it drips down the back of your throat, and then you swallow it. It’s called mucosa. ciliary flow. And, and I mean, it could be that you need that mucus in order to have enough of a mucus blanket to swallow your food to lubricate your food. So it actually goes down the esophagus, but I really I find it unlikely you could just upregulate the mucus that’s produced in your nose and your throat in order to have enough so that
was always my question was that if the chambers are just there to provide provide surface area for mucus production, that would be one thing, but it doesn’t seem to me that they’re necessary for that, but that’s where your perspective would be key here. I mean, that’s not the only place where certainly where there are mucous membranes but also where there’s mucus production, correct. Oh,
there’s mucus production. You know, all over the inside of your nose and the inside of your mouth, which should be more than enough. And if it isn’t, then you can up regulate it and you just did. And you would still need to swallow the same amount. It’s not like you would start drowning because you’re producing too much because because, you know, you’re producing the same amount of mucus just more localized. And we don’t find if someone has large sinuses or small sinuses. Some people have a trophic sinuses that they really have a deficit because of it. Some people don’t have frontal sinuses, so the forehead sinuses, they just don’t have them. And right, it’s fine. They don’t have any type of a deficit. So one thing that we used to do, and we really don’t do it anymore, is if you’d have chronic frontal sinus infections, we’d actually obliterate the sinus. So you’d scrape all the mucous membrane out of the mean, it turns out that that can turn into a disaster. So we don’t do that anymore. You’re
removing the like the sub mucosa so that it does, nothing comes back.
Exactly, exactly. You’re like scarring it, you’d pack it with fat to just fill it up. But if you left a single cell behind, then you’d end up in a mucus sealed with a mucosal in that area. And that would be problematic. So, but still, they would have complications from the surgery itself, but not because they didn’t have a sinus anymore. So it doesn’t seem like they really have a function anymore, but they can cause problems. And so something that you and I had spoken about was that, you know, in our modern society, since we live on top of each other, we get a lot of, we get more colds than we did when we were hunter gatherers out in the field in a tribe of, you know, far fewer than we’re around now. So you get a lot of colds and that can affect the sinuses and some people as a cold turns into, it starts out as a viral upper respiratory tract infection turns into a bacterial sinus infection, and that can cause all sorts, all sorts of problems that can cause brain abscesses and orbital abscesses. If only just or if you have asthma causes asthma exacerbations. Like these things can be dangerous. It rarely causes rarely causes the ABS disease, but you know, in terms of quality of life, you now you know, you’re not going to be someone that’s going to be selected for because you’ve got this foul smell coming out of your nose, lose your sense of smell. It’s very uncomfortable. So So you can live a long life with a chronic sinus infection, but you know, you’re probably gonna be, you’re gonna have a hard harder time reproducing in that setting. So these are they have a liability to them, at least our modern society. So the question is, where could they have come from and where could they their function have been previously that they still exists now?
Well, I think you you’ve, I think you’ve given us all the information to produce a pretty good working theory. First of all, I think that drawbacks to the sciences that you mentioned about infection and how how the poor design and the poor drainage can can make all of this the symptoms of restaurant frictions worse. All that’s true, but I don’t think it was a major plague on our species, until we started living in higher population density. So before farming was invented, and remember, farming was just very recently invented if you’re if you’re used to the type of timescales that I work in. So prior to that population sizes were measured in the low hundreds 150 to 250. So you just you weren’t ready ravaged by a cold virus very often. I mean, it went through if it went through the population once, and that would have been it, it doesn’t circle the globe and mutate and come back again. And all this sort of never ending onslaught of viral infection. I just don’t think that our pre historic forebears were very sickly people with infectious disease, because it just wouldn’t have been passed around. It would have, you know, like I said, Go through once. And that’s it. And with no host, and these, most of the groups were fairly isolated from one another, at least on timescales of years to decades, not not over longer timescales. But so I don’t think that we were passing around these effects, I don’t think it actually was all that much of a detriment until forming. And we have evolved very, very little since the 15,000 years ago that we started sort of being more sedentary and staying in one place and that and that’s what farming allowed. So I don’t think that we’ve even had enough time to experience the selection, pressure, and even even then, even if we do think of this as a major detriment to us, we’ve sort of escaped natural selection in that way. We don’t really live and die and succeed or not, based on how healthy we are that much anymore. cultural evolution has so outpaced biological evolution over the last 15,000 years. And that’s why you have like, no, the Hapsburgs of Europe were tremendously successful in their reproductive capacity, but because of their own poor reproductive choices, they were a very sickly group, right? I mean, they have words, their face wasn’t even formed correctly talked about the sciences. And yet, because of the way that that power leads to reproductive success in our species, it didn’t, it didn’t affect them in terms of the reproductive success. And I think that, you know, you map that phenomenon all the way back 15,000 years, I don’t think that the common cold was just very much of a selective pressure, even sinus infections would have to be very serious before they really affected your ability to reproduce,
but even a lot of sinus infections, bacterial sinus infections are self limited. So just because you have a sudden spectrum doesn’t necessitate antibiotics, but we do we do often treat them so so then where did the sinuses come from? The short answer is that
our sinuses are related to the sciences that all mammals have. But they almost all mammals have them in their snouts. Okay. And so every mammals outside of primates are snout if you think about a horse, a kangaroo, a dog, even bears, you have all of this room in the snout, and that’s where these large cavities can concentrate millions upon millions upon millions olfactory receptors. So the purpose of the smell is to really heighten the sense of smell. And that’s why they have so many more kinds of olfactory receptors as well. Every other mammal outside of priming is really driven by its sense of smell. And so the snout had enormous advantages, and they navigate their world through all the odorant receptors that they have there. Well, in primates, we represented a transition towards vision as the primary sense that we navigate the world away from smell and towards vision. And those two did end up intention. It would be great if we had kept the sense of smell while we develop vision but here’s why that wasn’t possible to really get the best view of The world you don’t put your eyes on the side, like horses and everything else. That’s great for a wide field of view, but you have very little overlap between the two fields of use of your eyes. And the overlap is what allows you good three dimensional stereoscopic vision at a distance. So if you bring the eyes forward, you have your visual field field covered by two eyes, you get good depth perception. The problem with that is if you bring your eyes forward, and you don’t reduce yours now, that’s now is right in the middle, it’s right in the middle of your field of view. So what primates did, while the eyes migrated forward, the snout regressed, and it got smushed in to our face, essentially. And that was great because it got it out of the way. And but it reduced our reliance on smell our ability to smell that well. And that was okay because we were transitioning towards vision. So there was really not not that big of a drawback. And more evidence for this, by the way is found in the fact that most of our olfactory receptors have now been lost. They’re all pseudo genes, not all of them, but we have several I forgot the number of just looking this up the other day, but I think it’s over 1000 olfactory receptors, pseudo genes. So these genes have been broken by mutation. But there was no effect because we’re not really driven by our sense of smell anymore. So as the snout regressed into the face, those sinus cavities still existed, and they just got mushed up into the bones of our face. And so if you ask me why we have sciences, it’s because our ancestors did. It’s not because they perform any important function for us. We can breathe through our mouth just fine. And in fact, anytime you do strangers exercise your most your most of the air is coming in through your mouth. And yet you don’t have any terrible effects of that. So I would, I would argue that the sinuses do seem to be these fairly vestigial in the sense that they were important to our ancestors. They’re not important to us. But they weren’t removed by evolution, because evolution doesn’t fix every mistake.
Yeah, you have to have enough pressure and without that pressure, then then it then it just
stays. The other apes did the same thing we did, but they handled it better. So for example, the orangutans ditched Some of their sinuses that some of the para nasal sinuses they just ditch them altogether. Somehow they did get lucky. And the mutation sort of eliminated those sinus cavities. So Ryan tans got the best end of this deal. chimpanzees have a very similar arrangement that we have, but yet the drainage from the maxillary sciences in particular, is wider. And it’s also higher up in the chamber so it doesn’t. So the mucus does isn’t allowed to pool at the bottom as much. So they have better drainage. They don’t suffer sinus infections like we do. They don’t live in the population densities that we do and
they don’t get colds. I mean, yeah, no, you know what they ship with the sniffles often?
Yeah, not really. And in fact, your dog also, you know, is a good example. They never really have upper respiratory issues unless you’re talking about a breed who we have smooshed their sinuses like the pugs and Pekinese and that should tell you something actually that that this mushed up side is is really our breeding ground for for infection and that’s what we have essentially where we are pugs in terms of how our assignment is we’re just sort of very quickly smushed in To our face and sub optimally designed thereafter,
I will be sure to tell that to my next patient with a sinus infection. You are a pug of the human race. Yeah, that will that will go poorly. One story and
that was Dr. Bradley Block at the physicians guide to doctoring. He can be found at physicians guide to doctoring comm or wherever you get your podcasts. If you have a question for previous guest or have an idea for a future episode, send a comment on the 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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Support for Physician Burnout Syndrome with Torie Sepah, MD

Torie Sepah, MD, completed her internship in family medicine at Kaiser Permanente Los Angeles Medical Center, then went on to complete a psychiatry residency at LA County + USC Medical Center. She has studied physician burnout syndrome extensively. It is a topic that is very personal to her and we discuss why. She defines the syndrome, what the major causes are, what the consequences are and what has actually been proven to help. Among them is connection.

Her Facebook group – Physician to Physician: Healing the Practice of Medicine, has become a signal in the noise surrounding burnout, providing us with a community of physicians who understand the hardships of our field and can help.  

She has worked extensively in correctional medicine, having served as the chief psychiatrist at the California Institution for Women, being the first female chief psychiatrist at that prison.

Since 2018, Dr. Sepah is a community psychiatrist once again, seeing patients with HIV in an integrated clinic and running her own interventional psychiatry clinic, which focuses on deep Transcranial Magnetic Stimulation (dTMS) as well as reproductive psychiatry, neuropsychiatric disorders, and early diagnoses or schizophrenia.

Dr. Sepah is an assistant clinical professor, department of psychiatry, Keck School of Medicine of USC. Prior to becoming a physician, she was a journalist and assistant editor of Ms. Magazine, writing the health column which prompted her interest in medicine. Dr. Sepah can be reached at her self-titled site, Torie Sepah, MD,  and on Twitter @toriesepahmd.

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!!!

This episode is brought to you by Orange County Bookkeepers (OCB) Healthcare Accounting: an all in one accounting firm for small healthcare businesses and private medical practices. One thing that I personally love about OCB Accountants, is that they are QuickBook professionals with over 20 years’ experience, focusing specifically on healthcare. They utilize a tailored approach individualized to your needs. They are a full-service bookkeeping firm specializing in accounting, payroll, taxes and financial planning. For our listeners, for a limited time, they are offering 25% off their services for the first 3 months. You can visit them at OCBmed.com or call 833-671-3873 or 949-215-6200.

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.

Teresa completed her internship in family medicine at Kaiser Permanente Los Angeles, then went on to complete a psychiatry residency at LA County USC. She has studied physician burnout syndrome extensively, and it’s a topic that is very personal to her. And she discusses why we then define the syndrome. What the major causes are, what the consequences are, and what has actually been proven to help among them, his connection. Her Facebook group physician to physician healing, the practice of medicine has become a signal in the noise surrounding burnout, providing us with a community of physicians who understand the hardships of our field and can help. She’s worked extensively in correctional medicine, having served as the chief psychiatrist at the California institution for women, being the first female chief psychiatrist at that prison since 2018. Dr. SEPA is back to being a community psychiatrist. seeing patients with HIV in an integrated clinic and running her own interventional studies. Ettrick clinic, which focuses on deep transcranial magnetic stimulation, as well as reproductive psychiatry, neuro psychiatric disorders, and early diagnosis of schizophrenia. Dr. SEPA is an assistant clinical professor at the Department of Psychiatry at the Keck School of Medicine at USC. Prior to becoming a physician, she was a journalist and assistant editor of MS magazine, writing the health column, which prompted her interest in medicine. Dr. SEPA can be reached at herself titled site Tory SEPA MD and on Twitter at Torrey SEPA MD
Welcome to the physicians guide to doctoring A Practical Guide for practicing physicians. Dr. Bradley Block interviews experts in and out of medicine to find out everything we should have been learning while we were memorizing Krebs cycle. The ideas expressed on this podcast are those of the interviewer and interviewee and do not represent those of their respective employers.
Now, here’s Dr. Bradley Block.
This episode is brought to you by Orange County, bookkeepers, healthcare, accounting, and all in one accounting firm for small healthcare businesses and private medical practices. One thing that I personally love about OCB accountants is that they are QuickBooks professionals with over 20 years experience focusing specifically on healthcare. They utilize a tailored approach individualized to your needs. There are full service bookkeeping firm specializing in accounting, payroll taxes, and financial planning. And for our listeners for limited time, they’re offering 25% off their services for the first three months. You can visit them at OCB med calm that’s OCB m Ed or call at 833-671-3873 or 949215 60 to 100. And check out the show notes for more information.
Tech tutorial purpose. Thanks so much for being on the show today.
Thank you so much for having me.
So there are a lot of misconceptions out there about physician burnout and physician burnout syndrome. And I actually never heard of it referred to as a syndrome until I read one of your blog posts. So I think if you just call it physician burnout, I might qualify for that. Because in the most general sense, I’m feeling pretty burned out right now I have a three and a half year old, a two year old and a four month old and they’re all sick and nobody’s sleeping. And we’re all miserable. And I’m feeling pretty burned out. But But that’s not what burnout is. Right? That’s not what we’re talking about when you’re when you specify as physician burnout syndrome. So how do you define the syndrome?
I’m really thank you for having me. And I’m very grateful that you asked that question. The definition is not insignificant. Because we have a way of, if we have a way of defining something, then we have a much better way of perhaps utilizing interventions that might be effective. We know there is a definition of burnout syndrome. And we’ve had that definition actually, for some time. It’s based on the work of a psychologist who was in a seminal psychologist in organizational psychology, Dr. Maslak, who defined through lots and lots of research, the burnout syndrome as a three prong syndrome involving emotional exhaustion, which basically means what it is, you know, you have really nothing left to give. And then secondarily, something that I think is a little bit poorly worded depersonalization was essentially means having negative feelings towards patients. And then lastly, having a sense of low personal accomplishment. So these three indices together when they reach a certain level, define physician burnout syndrome. And we actually can measure that using historically it’s been the MBI or the mass lack burnout index in most. And it’s why it’s important is because I often see that is referred burnout, burnout, burnout is referred to so many different situations that are not necessarily physician burnout, are but our stress, for example, or physical fatigue, which everyone can have and everyone will. Those are are not the same as physician burnout syndrome. And the ramifications of those are not the same as physician burnout. And our interventions for those should not be the same.
So with regard to interventions
have the following which do you think are the most useful for treating?
burnout syndrome? physician burnout syndrome, is it? Is it meditation, yoga or vitamin injections? Which of those three do you think are the most useful? I’m just kidding. That that is that’s, that’s right. Because that’s, that’s a lot of what we’re being told now is like, I’m sorry that you’re, yes, you’re going through this, you know, you should do try meditating, or journaling, or do you know, right? Like, those are the solutions that were being given.
So that’s exactly right in there and the elephant in the room if you realize the fundamental problem with Those three solutions, what’s the what what is the problem there? What do you think it’s not that there’s anything wrong with yoga or meditation, I always say those have shown to do actually meditate mindfulness and yoga do reduce stress or a three month period, you know, in studies, we see that they can sustain or sustainable at least for right now for a three month period and reducing stress. But what is the fundamental problem, when we look at physician burnout syndrome and using those is that where they are placing the burden of the problem is on the physician. So the message is, you are lacking something either you’re too tightly wound, you’re too you’re not, you’re not relaxed enough. You’re too stressed out. All of the reasons and all of the ways in which you were selected. To really perform and excel in this profession, which is how you got this far, we now want you to actually undo that. And go learn yoga, stop checking labs on patients at night, because apparently that’s stressing you out and burning you out. We want you to now go learn how to become mindful on your weekends, by the way, and sign this form saying get it on your own time.
But we’re not going to find someone to check those labs for you. You’re still going to be responsible for checking those labs. Just make sure you do your yoga before and after you check those labs. Because if something happens, you’re still responsible for it.
Okay, so what happened with that that has been the most troubling component is that we skipped a lot of steps in not addressing physician burnout. appropriately, we went from, oh, doctors have quote, burnout. Therefore, it must mean they can’t control their own workload. They don’t have lives. They don’t know how to control their stress, something is wrong with them. So let’s start sending them to mindfulness training. And yet, we don’t really know whether that works or not. And now nobody asked. We’re just giving more putting adding more to these physicians place now we’re now we’re telling doctors, not only are you have a stress case, you’ve got to now learn how to become a mindful stress case. So you’ve got to learn mindfulness. In addition to checking your inbox and getting through the 30 tasks, you’ve got to do it in a mindful way.
My favorite is when you get the incomplete because you, you haven’t taken that hour and a half course yet on mindfulness, so we can check the box that says that we are As an organization are addressing physician burnout, that was definitely something that I had to do for one of the hospitals where I had privileges It was just something else to add onto my plate as if I didn’t have enough.
Exactly problem. Any assumption, the underlying assumption is, the problem is with the physician. The problem is you’re either too wound up or conversely, by the way, you’re not resilient enough somehow. And if you weren’t, you lost your resilience. I always say this, how, how is that possible? So somebody was resilient enough to get to medical school, residency, you know, all of that and all of a sudden, they’re not resilient enough. They need resiliency. They need to go and learn resiliency all over again. How does that happen? How do you lose your resiliency? Why don’t we step back and look at what the actual contributors to physician burnout syndrome is, I found down at a table with people who are at the executive table of companies, healthcare institutions and said, you know, their intentions are very well, they really want to help physicians. But there is this place that they start is completely wrong, which is their starting at all the way out in z where they don’t start a which is, first let’s start with what is this? What is physician burnout syndrome? What isn’t it? Then from there? Let’s go to what are ways and what are the evidence based interventions if there are any By the way, and then from there, what are the why does this matter? Why would we want to address this? What are the ramifications of this? How, why are we all invested in this not just as physicians, but As a community, why does this matter to patients, to nurses to administrators, etc, lawyers, etc through that discussion, I rarely hear in that way. Most of the time, what I hear is a company will have physician coaching mindfulness training, they’ll have a retreat for doctors, they’ll have somebody come in, give a speech, about how to increase their resiliency, and improve their balance their workload.
So it seems to me that this is similar to what the the general public thinks is wrong with doctors in that, in that when a patient comes in, we’re trying to treat their symptoms. We’re not trying to treat the underlying problem which is completely untrue. Because it’s not like when someone comes in, we don’t do we do our best to try to get them to move more and increase their physical activity. And, and eat better and is we’re not just trying to get them to quit smoking, we’re not just trying to push pills on them, we’re pushing pills in them, because we’ve tried all those other things. And, and they don’t work. So we’re just we’re just doing the best we can. So we’re trying to get at the underlying problem, not just treat the symptoms, but it sounds like in this situation, they’re just trying to treat the symptoms. They’re not trying to get at the underlying problem, although arguably, it is very hard to get like to make big system changes like this is much more costly. And it’s much harder than, you know, a yoga retreat or whatever it is. But so, so, so let’s talk about that. Right. So the symptoms of physician burnout syndrome, emotional exhaustion, depersonalization and a sense of low accomplishment. Yes, what are the causes?
Good question. So the the causes have been pretty consistent, I must say consistently identified as being the same Since we’ve been measuring them in the last decade or so, the top contributors are loss of autonomy, electronic medical record system and having feeling I I just read the new the newest study that came out by medscape, which is feeling like a cog in a wheel, which I think is also related to loss of autonomy. Those are essentially the top two have been loss of autonomy, the impact of the electronic medical record system. And the shift to the shift in healthcare system from administrative large administrative burden has been the consistently identified over the last decade as the root contributors to physician burnout.
I would say that with no expertise in this area, but I would say that You could probably lump EMR into increased administrative burden because what you’re doing the problem I don’t think is the EMR itself, right? Like I can now read someone’s chart and figure out what’s going on without having to translate, you know, someone’s horrible handwriting. So and then I can use dictation software, you can use a scribe, we can have templates. So there are a lot of ways in which the EMR is actually a good thing. It makes us more efficient. But the all of the garbage that we have to enter is, is unnecessary. And but but it’s it’s been put upon us by the powers that be. So I think that you could really lump into the administrative burdens, because it’s not the EMR itself. It’s it’s the administrative burdens that are cooked into the EMR so that the data can be collected and used by someone far away and not actually help the physician and help the patient at the time.
Yeah, overall, you know, it’s true. There’s a lot of overlap in the way the one can look at this one can interpret the studies and the way the, the wording on it is described in terms of causes. There’s quite a bit of overlap. For example, the top radiology most recently recognized is excessive charting paperwork, okay? But then there’s, again increasing computerization and practice. Well, those two are very, you know, intimately related. And then there’s loss of control and autonomy 24% say, contribute that say that is the main contributor but then 22% feeling like a cog, a cog in a wheel. Well, those two are very similar, correct. So, there seems to be overall a very consistent message. That there is a disconnect in terms of physicians feeling that they have a voice in their work in the design of their work. And also feeling a disconnect in terms of when it seems work ends and begins, which appears to have appears to be related to both the inefficiency of the electronic medical record system but also the problem with electronic medical record system continuing to be on correct. So I have an app right on my phone. It gives me messages constantly. That you know, there’s an inbox in there Hey, patient message with a refill this this inbox, lobstering you know and that is really actually disruptive. You know, I’m at my
you need to get that off your Phone. Yeah, exactly. That sounds horrible. I don’t I don’t have that on my phone, I have to log in on my laptop on my system. So when I, you know that way, you know, at least the way that my practice work, we have a doctor on call if there’s an emergency, they’ll call the code, right? There’s the they’re these things away that that they’re these barriers, which, you know, there are barriers for the patient, but ultimately, they insulate us from having to have that feeling of being on all the time.
And that it’s important that that is, you know, I talked to so many doctors and they’ll say, What do I do? I’ve been told to download this app. You know, am I supposed to check it all weekend? These are gray areas, though. So these are new gray areas. These are not we don’t what I always tell doctors and I learned this later in life. Where is it in your contract? Where is that app? Your contract?
You you’ve got to you’ve got I guess a solution to that would be sort that out. Talk to whoever’s right so you’re not you’re you’re whoever that is, whoever is getting those messages is not the owner of their practice. They’re your lawyer, because if they were the owner, it wouldn’t be such a gray area. Well find out, address it, address it, don’t be afraid find out where your responsibilities starting and and do your best to get get protected time.
That’s where we also have a problem as physicians and that’s not. And when I say problem, it’s this is probably something that I spend the most time talking to physicians, both in our group and individually is this isn’t about resiliency, but this the culture that we learn. Madison is one of stoicism. So we don’t ask whether we’re supposed to see that patient on that time, we will usually do what we’re told right at training. That’s how we are praying. I mean, I’m not proposing that that’s the healthiest way of learning medicine but that’s the culture in which we learned how to become physicians was not by placing limits or boundaries.
Yeah, if you don’t wake up at midnight to check that lab, you clearly don’t care about your patients. Right? That’s what the messages,
you’re not going to make it, you’re not going to finish residency. And so we have been, it’s hard wired in positions to grin and bear it. And we are a group that has a very difficult time, setting boundaries for ourselves and saying, Hey, you know, do I have to check this app all weekend long, or, you know, I mean, does it make you feel well, maybe I’m a bad doctor, if I take this app off my phone? Geez, you know, maybe I’m supposed to I mean, I you know, that’s what I signed up for. I mean, I’m a doctor, I, we just don’t do that because we’ve never, never done that. One of the things that I am trying to work on collectively. Lee is identifying the difference between becoming stronger as a group of physicians does mean, identifying what we are capable of doing long term and maintaining that is actually gonna have impact on our patients. So we will be better doctors, if we can say, Okay, how about how long can I sustain this? How long can I really check these, you know, this app every weekend, you know, and still love what I do and do it well and have a have a life that’s fulfilling. And in order to do that, it means having a conversation with other doctors saying hey, do you find that this is this is kind of intrusive, or what are your thoughts and as it’s much easier When you approach it as, as a group of physicians, then by yourself and having physician commodity, you know, we have a much stronger voice. When there are a few of us than just one of us.
I think that is an excellent segue into talking about your, your Facebook group. Great, right? You’re the the power of the community, the power of connection. So tell us about the Facebook group. And then you know, starting with with its origins, why, why did you start it? Why is it so personal to you?
Yes, yes. And I started it in a general sense, there is an evidence base, one of the truly, probably the most consistent and the highest level of evidence based intervention for physician burnout syndrome is peer to peer. That’s true peer to peer that means physician to physician support and Ideally, it would be one hour a week during the workweek, by the way, without any administrators or supervisors in the meeting that has been, you know, shown in randomized control trials even to reduce physician burnout and prevent it. I did a study in residency on physician burnout syndrome, when I was a third year resident in psychiatry comparing burnout between two specialties and also between residents and attendings, and we were pretty surprised that our residents did not have a reduction in resident in their burnout syndrome. As they escalated through training, meaning as their call dropped, and our attendings had higher burnout syndrome, then attendings in another specialty, despite having, you know, essentially no call right? something was amiss. That was in 2011 when I did that study, and there was a wake up call when I did that study. In it was a big program it was at us LA County USC. So the N, if you will, was large enough where, you know, the results were, were significant. And we, as a result implemented, approved a peer to peer group for one of the resident classes, which was a third year resident class and I left the group as a pilot, I found from that that was the starting point. And I did that for another three years, expanded it to ob gyn residency, etc. Fast forward years have passed and physician burnout, you know, there at USC LA County. That model actually built on itself every class now and as a group apartment actually has a peer to peer group and is, you know, self sustaining. I returned it to this concept when one of my classmates from medical school took his own life, two years ago, it was quite a surprise to me. He was, you know, somebody who was, you know, I was shocked, I have to say I felt a degree of blame because I had been in contact with with him on Facebook and you know, he hadn’t come to our reunion and I had reached out and I’ve noticed some, some things, some signs on, you know, some pose, but I had really been dismissive of them even as a psychiatrist because he was a physician. I just thought, Well, yeah, I’m just I’m reading too too far into this. She’s fine, you know, and, and I’ve deeply regretted not reaching out and not doing more to find out how he was doing. I was very troubled by his loss because it wasn’t just a loss for for me in terms of a friend but it was a loss for his community, the loss for his patients because anytime a physician takes their life, we lose 3000 Patient contacts just a year. So physicians are there’s a multiplier effect. So we lose a million patient contacts a year just due to physician suicide. And Jason was a veteran. So very unique position in that sense and his connection with patients. I just felt it was a tremendous loss. And when I went back and looked at statistics of physicians who do complete suicide, I was rather shocked at how little we know about physicians who complete suicide, but what we do know is that 85% of them do not access any psychiatric care, including not being even diagnosed with depression or anxiety, and most of them are feel lonely and isolated. If that made sense that made a lot of sense to me. He had recently moved to a new state and it seemed that a community was something that had been protective. Not just for Jason, but his protected had been protected from me when I was in medical school and residency, something that I desperately missed even as I was progressing in my career in it would be ideal to set up in person groups for physicians, I felt, if at the minimum, I could set up a virtual doctors lounge, if you will, where there’s a safe space for doctors to just say how they feel, maybe maybe we can, maybe they can reach out to me Maybe I can help get them up, you know, somebody they need to talk to you or I can they can just feel like they’re not alone in how they’re feeling. Maybe that would prevent somebody like Jason from becoming increasingly isolated, and feeling getting to the point that he did. And that’s how it started. And we now have close to 3000 position members. It’s been incredibly gratifying to have a place where doctors can go to to
say how they feel if they’re having a bad day. does appear to be that physicians will open up to other physicians more readily. Which makes sense. It makes sense, right? Human beings are tribal. And, and physicians are a tribe. We get each other right. We have this, this experience in the same way that particular to, to Jason Yeah, veterans, right? They have this is unique lived experience that only veterans get that only veterans understand absolutions. You know, I’m not comparing the two experiences, we don’t go through what they go through. But we do have this unique lived experience that only other physicians get. So it makes sense that we’d open up to each other because you know what, I know the person reading this gets it. I know, they get it because they went through what I went through, they’re going through what I go through,
and they and you important. One of the things that we worked very, very hard on into crew is for four of us now who are the administrators in the group and We work very, very hard having physicians learn how to mentor each other in the group because we treat each other sometimes worse than we treat anybody else. Interestingly, because that’s how we learned to be. It’s like how you treat family sometimes. So a lot of it is really learning and modeling. We are, you know, we go back to very interesting to see, to see physicians, and I’m certainly not perfect. And I’ve done this as well, which is we can regress back to our training days when we learn in a specific way. And when we are stressed, we’re not always the most tolerant with each other, by the way we are with patients, but we’re not with each other. And part of what we work on in the group is learning to not have an answer for each other. We’re not here to judge other physicians or I’m not here to tell physicians what to do. We’re not here to give people you know, their you know, a path to this is the thing to you should do to not do that you shouldn’t done that. Most of the time, what the group we’re we’re trying to teach physicians is building camaraderie, true camaraderie, which means listening and accepting the physicians because we need each other. In the end, not a lot of physicians anywhere actually, wherever you go, we’re always just a few of us. And that in itself is a significant goal is relearning how we relate to each other as well because we are very, we are more comfortable being not so great with each other at times. And that is something we also work through in the group. And we can’t afford to turn our backs on each other. There’s not enough physicians. So we work on that in the group as well. You know, We give people a lot of chances in the group, you know, a lot of feedback on how to combat you know, let’s let’s approach this this way let’s work together because we want we have young physicians, we have older physicians, we have male physicians, we have female physicians, we want a group that is truly diverse, and reflects the reality of the physician workforce. Right. And that takes a lot of work to sustain all of these people having conversations, right. But that’s important. That’s the other facet of it is being able to hear each other among the noise.
So you took this this issue, right, that led to the loss of your friend and colleague, the isolation and you turned it on its head, right you gave you you created this forum for connection. So that was your response to that. I think that’s incredible. And I think the fact that we have so many positions that being said, there are a million physicians in the country, right? And only 3000 of them are on this Facebook group and I’m sure, tons more are would be would be helped by this. Right? more connections because it’s just exponential right? The more physicians you have, the more positions you can connect with each other. And the more we can we can help each other and create recreate this community. Right. And I think it’s just like you said, it’s from our training in our training, right? You have to go it alone, you got to do it alone, you got to achieve and you got to beat your competitors. You got to beat. Yeah, your classmates, your ranking class needs to be better than theirs if you’re going to get the competitive spot. And now, we have to look past that and work together. And yeah, there’s a lot that we’re up against. Right?
We will not make it if we’re not going to be a solid group. So we won’t survive because we are out number in every This is the first year 2019 where there were more physicians employed and owners of practices. So And that means that in any administration, there’s never going to have a majority of physicians, right? And we’re only
headed more in that direction, right? The more complicated this gets, the more infrastructure you need for billing, the more infrastructure you need for your electronic medical records and charting, the less you’re going to be able to have a physician run practice, the more you’re going to need the infrastructure of a much larger organization. So it’s, it’s only going to get worse, it’s not going to get better.
That’s exactly right. And if we have to learn and this is something we talked about, also when the group is I think, we have some divided and subdivided and more can our little tiny into our sub sub specialties. It’s like, read diet, you know what, like, you know, not just psychiatry, but it’s like,
oh, yeah, I can. Yeah, and in, in my field, right, like, I’m not specialized enough as an ear, nose and throat doctor, we have right ologists and otologist syndrome. otologist facial plastics Yeah, yeah, yeah. Or ophthalmology. Wow, like,
retina. There. Is
there a different we had an episode of that a little while ago, where apparently they’re eight, eight subspecialties in ophthalmology. It’s it was and I’ve always an ounce and you have eight different fellowships
and everybody and here’s the thing is I can tell you right now because I’ve sat you know I had the the true privilege of having a seat at the Big Boy table and that hurts us extremely. When we are so subdivided and can’t see beyond our sets of subspecialty. We’ve got to be a fit, we’re physicians or we’re going to fit that’s how we get pay disparity. That’s how we get essentially moved into this position of not having very strong bargaining power. We are not very powerful in our you know, as a one forensic science coyotes just like in the hospital, you know, it’s just like, so what if I think, you know, I click 86 times to close, who cares? I mean, there’s like one person, right. Whereas, as a group, we actually have a voice. We, you know, we each physician creates 17 jobs 17 to spite existing. Okay, that’s quite, we also don’t know our worth. That’s the other thing we’re incredibly we’ve managed to not understand our our impact on the larger economic ball. That’s why
we direct so much of the money in healthcare, right, the healthcare is just, it’s a huge percent of the GDP and who’s deciding how that money is spent? physicians. So our impact on the system is true is tremendous, is tremendous.
And if we actually were able to see or solve as we did in medical school, as physicians, or as med students as one unit, you know, and even in residency, I can We will probably be more cohesive than we become as we kind of progress, you know, we start to fall more and more into our specialties and it does not benefit us. And we know that if we look at the bills that we’re seeing go through in terms of Medicare reimbursement, we know it’s not helping us to be seeing ourselves as such specialists and specialists know that we’re losing. We’re you know, we are not because there is no, I should say there’s the American Academy of nurse practitioners. There’s the American Academy, there’s the American Psychological Association. There’s not the AMA is then there’s a me but then there’s also then all these other subspecialties, right, there’s like the APA. There’s the AFP and we’re, you know, we’re all over the place and we have not really stood behind one strong lobby and it shows I’ll tell you that your number of residency positions that are increasing at 3% per year, as opposed to our medical student admission rate has gone up 10% which it should they adjusted their rate, but Senate has only approved a 3% increase in terms of residency position. So we have 7%, whereas this gap, so we have found more than 1000 physicians in the US we create each year. We’re standing there, unmatched. Okay. But just to end then we’re talking about a physician shortage and increasing provider status for everybody we can, and we have more than 1000 physicians standing there every year. And that partially is because we’re not quite united yet in the network. But we were still thinking about what what little subculture psychiatry to our block, right.
Well, for all its flaws. Yeah, this is one place where Facebook I think, has been a great benefit because I’m a member of the physicians on social media. Ah, that Donna Cornell’s Started, right that’s, that’s just growing exponentially. So now I have this community of doctors on social media. I’m a member of passive income physicians and the white coat investor Facebook group, because here’s another, if you can gain financial independence, then if you’re suffering from burnout, you’re financially independent. So you can go tell your employer to screw off. And you can find a job that works for you and work and work on your own terms. So they’re all you know that with regards to social media, we’re able to amplify each other’s voices. And then with your group, we’re able to find a community to help us, right, it’s physician to physician healing the practice of medicine, so we’re able to help us heal each other, heal each other through difficult times. So for all Facebook’s flaws in this one regard, it’s really helped us to coalesce in these communities, which might be disparate, but right, like I would have never interacted with you for my entire life, had these things not existed and now you know, we’re able to amplify each other’s voices and can with each
other, I completely agree Facebook has changed the way physicians organize. We have grassroots organizing we’re doing we are campaigning for, you know, patient sprites on Facebook. I mean, we finally have a voice. I think we found each other. I mean, where it sounds really cheesy maybe but you know, where we finally, I think are we are utilizing it in a way that is beneficial both in creating a community that’s helpful for us, and ultimately is going to have a larger impact on improving healthcare, because if doctors are healthy and staying alive and happy, then we know that trickles down, we know that we know that from study.
Oh, well, that’s Yeah, that’s a whole other issue is that physician burnout syndrome affects patients patient outcomes. And it makes sense, right, because one of the symptoms is depersonalization. So if you depersonalized your patients, right, that that will ultimately affect their outcomes. Well unfortune We can’t open that door right now because I know you have a patient to see and I’ve got to go pick up my kids from school. So we’ve, but it’s really been great talking to you. Where can people find you online?
Yes, I can be well on twitter at Torres SEPA and di t o r i s EP h empty. And our Facebook group, I think the best way is to just look at the link it’s for we go through a it’s not a no, it’s a closed group. So we go through a vetting process for physicians and physicians and training. It’s called physician to physician killing the practice of medicine. And my website is based. It’s linked to my practice in large part but it does have a link to the my writings on Kevin MD. So it’s www dot. Tory’s efa. md calm.
Well, Dr. Theresa, thank you so much for taking the time. It’s been great talking to you.
Likewise. Thank you again.
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 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

Discussing Flipping the Script on Health Disparities with Max Jordan Nguemeni Tiako

Max Jordan Nguemeni Tiako is a 4th year med student (out of 5) at the Yale School of Medicine and hosts his own podcast, Flip the Script, about healthcare disparities. He starts out discussing how some of what we learn about race being a risk factor for some diseases are a product of social constructs, not genetic predisposition. We then discuss racial disparities in substance-use disorder treatment. We then pivot from health disparities to physician training disparities. We learn about the hardships faced by minority medical students from microaggressions from students and faculty to disparities in grading and how this can affect career trajectory. He ends by discussing some pearls he has learned from his own podcast.

Mr. Tiako grew up in Yaounde, Cameroon, and moved to the US to attend Howard University, got a BS in in civil and environmental engineering and then a Masters in Bioengineering from the Georgia Institute of Technology. He is currently doing research connecting his civil/environmental engineering background to identify elements of urban design that can be leveraged to improve health outcomes and move the needle towards health equity. His research fellowship is at the Center for Emergency Care & Policy research at the University of Pennsylvania. He spends his free time writing about racism and medical education in the medical student magazine InTraining.

His Twitter handle: @MaxJordan_N

His podcast can be found here:

iTunes: https://podcasts.apple.com/us/podcast/flip-the-script/id1402777078

Soundcloud: https://soundcloud.com/yaleuniversity/sets/flip-the-script

Spotify: https://open.spotify.com/show/1judlJj8gLg8OnVJtpXv7O?si=snZWGMbaRiafUfJZajHRyw

This episode is brought to you by Orange County Bookkeepers (OCB) Healthcare Accounting: an all in one accounting firm for small healthcare businesses and private medical practices. One thing that I personally love about OCB Accountants, is that they are QuickBook professionals with over 20 years’ experience, focusing specifically on healthcare. They utilize a tailored approach individualized to your needs. They are a full-service bookkeeping firm specializing in accounting, payroll, taxes and financial planning. For our listeners, for a limited time, they are offering 25% off their services for the first 3 months. You can visit them at OCBmed.com or call 833-671-3873 or 949-215-6200.

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.

Max Jordan, England, Jaco is a fourth year medical student out of five at the Yale School of Medicine and hosts his own podcast flip the script about healthcare disparities. He starts out discussing how some of what we learned about race, being a risk factor for some diseases are actually a product of social construct, not genetic predisposition. We then discuss racial disparities in substance use disorder treatment, and then pivot from health disparities to physician training disparities. We learn about the hardships faced by minority medical students from microaggressions from students and faculty to disparities in grading, and how this can affect career trajectory. Hands up by discussing some of the pearls he’s learned from his own podcast. Mr. Chaco grew up in yone de Cameroon and moved to the US to attend Howard University, got a BS in Civil and Environmental Engineering, and then a master’s in bioengineering from the Georgia Institute of Technology. He’s currently doing research conducting his civil environmental engineering background. To identify elements of urban design that can be leveraged to improve health outcomes and move the needle towards health equity. His research fellowship is at the center for emergency care and Policy Research at the University of Pennsylvania. He spends his free time doesn’t sound like there’s much writing about racism and medical education in the medical student magazine in training.
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.
This episode is brought to you by Orange County bookkeepers, healthcare, accounting and all in one Counting firm for small healthcare businesses and private medical practices. One thing that I personally love about OCB accountants is that they are quickbook professionals with over 20 years experience focusing specifically on healthcare. They utilize a tailored approach individualized to your needs. There are a full service bookkeeping firm specializing in accounting, payroll taxes, and financial planning. And for our listeners for limited time, they’re offering 25% off their services for the first three months. You can visit them at OCB med calm that’s OCB m Ed, or call at 833-671-3873 or 949215 6200 and check out the show notes for more information. Max Jordan go mini Tiago. Thanks so much for being on the show today.
Brad, thank you so much for having me.
So, why was it necessary to make your podcast Why do you feel compelled? You’re a busy medical student you have enough on your plate enough studying to do all the rest of the responsibilities that comes with a medical student. Yes, that you decided you were compelled to create this podcast. Why was it necessary? Why is it so important to tell this story for me I you
know, I listen to a lot of podcasts. And while in medical school, that was one of the ways I just sort of entertained myself and one of the sort of struggles in med school so far has been that the quality of our education when it comes specifically to health inequities isn’t particularly great just about anywhere across the country. And so, you know, a lot of times as a black medical students, and I am sure other minority medical students may identify with this. Now we find ourselves either engaging in conversations with our colleagues related to health disparities, especially for those instances where perhaps some of our colleagues have lesser exposure or lesser awareness. Two issues related to racism and equality in this country. And some of those compositions can be toxic depending on the type of setting. For example, in med school, where I go to school at Yale, we have a ethics and professional responsibility course. And some of those sessions health inequities come up or in our public health and Epidemiology course or even in our main lecture, you know, sometimes, you know, one of the lecturer may be giving a lecture or a sale on glaucoma and then nearing the end after we’ve talked about the pathophysiology, and the pharmacology, all the sort of like basic science and clinical aspects of a disease, a little bit of epidemiology gets presented and race as a sort of, how do you call that race as a risk factor is often presented alongside other risk factors that are not social constructs, like say, for example, for glaucoma history of diabetes. And so the sort of conflation of race as a biological factor when truly as more of a social construct and That race by itself is isolated by itself. Race isn’t so much a risk factor, but rather exposure to racism really made me want to share more of this with the world in a way that didn’t feel as taxing as, as was the case early on in med school, sort of like repeatedly engaging in this very much the same conversation over and over.
So you’re saying it’s not like say Tay Sachs, right? So right, Ashkenazi Jews, they have this mutation, where if two people with this mutation get married, they have, you know, a quarter chance of having a child that has Tay Sachs, right? So this is being a Jew right myself. We still don’t we don’t know. Like, is it a race is a religion. Is it a culture Is it fine, whatever. But that being said, right, that is genetic. So what you’re saying is when the professor is saying that, being African American puts you at higher risk for glaucoma, you what you’re saying is it’s not something inheritable. To the genetics of that individual, it is things that occur in society that put them at higher risk of glaucoma.
Well, so specific to black holes. Now what I would say is the evidence isn’t clear. And so the way it’s often presented, it’s as if it is clear, right? So for example, you’re right, like so illness like Tay Sachs disease? Well, yes, we know about the genetics. And truly those sort of genetic or things that have been shown to be linked to a specific alio are more so related to like ancestry, right? So for example, sickle cell disease is more prevalent among people from Sub Saharan ancestry. Like I grew up in Cameroon. I know so many people who had sickle cell disease and part you know, because of the sickle, the sickle cell trait, and a theory that says the sickle cell trait is supposed to be protective against malaria. So that by itself right, should not be conflated with the fact with like, with black race, in the context of being in America, and even Then Right, so the sickle cell trait is as common in some parts of the Mediterranean, you know, in some countries or regions of country of countries that are adjacent to the Mediterranean Sea. But then you have social factors like access to premarital counseling that are way more, you know, prevalent and say, most parts of like Spain and Greece that aren’t the case and say, in Cameroon, and, of course, then if you don’t have access to premarital counseling, the likelihood of two people with the sickle cell trait, you know, having children together is way higher. So it’s not as straightforward as sometimes we make it seem in the way we we teach race and genetics. And then the other thing is just about your average African American has like something like 25% Caucasian ancestry, right. And the way race is defined in the US is a self identified thing, right? Like so you have African Americans like who self identify as black like Barack Obama, who is however biracial, right, just the way we race was constructed in this country as more around how you’re perceived, and how you self identify and the history of like the one drop rule. And that by itself cannot be used to teach medical genetics, if that makes any sense.
Yeah. Because the way you perceive someone, if you’re then using it to weigh their risks of having a certain problem, might not be genuinely something that should be weighed in there.
Right? It’s not scientific. Yeah.
Yeah. Interesting. Interesting. Okay. So I can see where that would get taxing because you’re hearing it from an authority over and over. And each time you want to raise your hand and be like, yeah, and a shake them like that. It’s just it’s not that straight. Let’s not Stop saying that. I keep hearing that over and over until your best platform for communicating that information was great in your podcast. Yep. Exactly. Because there are people that want to hear and there are people that don’t write there are people that that just want to continue living the way that they’ve been living. And thinking the way that they’ve been thinking not have something changed their mind, because this is what they know. And this is what’s been working for them. And yeah, I’m sure you encounter that all the time in your where you’ll you’ll start talking about something and then you encounter resistance.
Yes, that’s also the case. But I will say right in the context of medical education, it’s important that we get taught what’s true. And this is a debate that comes up a lot, sort of like how do you change the minds of the quote, quote, unquote, Old Guard way of how medicine was taught versus how it should be taught today, as we have so much more advances, you know, when it comes to social science and medicine? So certainly, the podcast itself allows me to disseminate you know, the work of other sorts of social scientists and epidemiologists and physicians and all these people who do fantastic work related to health disparities. It also makes it such that if I ever get in a discussion about any given topic, but someone who you know may be skeptical because I know Maybe sometimes as a black medical student, there’s a perception that my position may be bias because I’m black. And thus I, you know, have a conflict, conflict of interest. So we’re like, well, there’s an anthropologist who did this very work. And I’ll send you the link because she was a guest on my podcast. And that kind of ends. If that makes any sense.
Yeah. You have a bibliography. Right. Yeah. That’s great. And, you know, something that I found an advantage of my podcast is if I have a question, I could just find an expert on it and invite them onto the show. And there you guys, I get my
answer. Right. Yeah, exactly. And I’ve gotten to learn a lot by doing this myself. So
so that’s that was gonna be one of the things that we can discuss. Excellent segue. So what are those? What are the some of the issues that that you’ve discussed that you maybe weren’t aware of before that have been particularly enlightening? So some of the things that you learned from your podcast my
first guest was Professor Colin Roberts at Yale College and history and Africana Studies, she studied the role that physicians played in the British transatlantic slave trade and as well as the sort of birth of the pharmaceutical industry way back during the slave trade, like, for example, one of the things that I learned is the pharmaceutical industry that we know today and the center of that context of mass production of medication came out of actually it was sort of born out of the out of the transatlantic slave trade where they were up. How do you call the apple tech carries? I don’t know how to pronounce that. Well. apothecaries. Yeah, there you go. Yeah. So for example, GlaxoSmithKline traces its roots all the way back to slavery, or, for example, the medical examination that physicians had to perform on those that were captured and, you know, at the cost of the African continent, and then brought on to the boats and how, you know, physician had to sort of force them to remain alive. You know, there was a lot of force feeding that happened on these boats or ships, I guess I should say, lots of force feeding, making sure that people remained as healthy as possible. And there interestingly, you know, what Professor Roberts describes because a lot of her work was archived All she knows she went to the UK and dug up letters that some of these physicians wrote back to their wives in the UK about what they were doing. And some of them were conflicted about what they were up to. But there was such a good financial incentive, while poverty may have been breaking back in the UK that they felt like well, you know, this is what I got to do. And it speaks to the eyes to me as a medical student now, right like thinking about the Hippocrates boats off, right, like, Who are we what is our allegiance to, to our pockets or to the board to people and people that were meant to serve, and society. So that’s one of the things that I’ve really liked. It really sat with me after I did that recording, another set, sort of like learning experiences for me amongst all my episodes was about this concept of a two tiered system of addiction treatment that we have in the US and the guests. The first guest I had on this was a professor Helena Hanson. She’s a psychiatrist and anthropologist and a You and this is the first time I had to like travel somewhere to interview. I guess it was really exciting. So basically, you know, the US has a history of splitting how we treat opioid addiction, right methadone versus buprenorphine, where buprenorphine is basically it, you know, the partial agonist to the new receptor versus methadone, which is a full agonist. And as it turns out, even an orphan is more accessible in areas that are richer, have more white people, less black people, as Hispanic people and people that are more more likely to be privately insured. And methadone is more, you know, accessible to black and Hispanic people and just the nature of how people access methadone versus buprenorphine. It’s really there’s a stark difference there this concept of the carceral state, but you know, but not within carceral institutions shows up in the provision of methadone, right. You have to show up to a clinic every single day and somebody has to watch you take your medication then you have to pee in a cup for a day. You and drug test. I mean, some people do eventually sort of quote unquote, in the trust of their provider and get to be able to, I don’t know, get a month a week’s worth of supply of methadone as opposed to showing up to the clinic every day. But overall, it’s a very invasive and intrusive process. And it’s almost like wonderful co wrote about the carceral state. And it’s sort of like, just uses throughout society, he thought about how methadone will be provided. Whereas with paper norson, you know, you can go to your doctor like you, you go get, I don’t know, your prescription for I don’t know, an SSRI, and then you go to the pharmacy, and then you pick it up. But, you know, it provides some level of privacy and normalcy that being a methadone patient just doesn’t and it’s a highly racialized, and that’s one of the favorite episodes in terms of just how much I learned from talking to Professor Hanson.
The interesting, you would think if there’s a method of treating something that is in an economically disadvantaged area, you’re doing it in a way that costs more Right, like because although it’s very labor intensive to have people come in, and it just it like from an economic standpoint, if it just doesn’t, it just doesn’t make sense.
You know, I have actually never thought about that until now. I mean, you know, methadone was introduced in like the 70s. And Duke wasn’t FDA approved for serious disorder until like, 2002. And before then people were sort of using it, I’m prescribing it off label. So I think part of it maybe the sort of latency with court, you know, people getting with the times, but even then, most recently, New York State just disagreed. I think maybe the governor vetoed it. I can remember the detail behind it, but basically, the state legislature, and the governor’s mansion in the state of New York got in the way of making sure that the orphan will be equally as accessible as methadone, basically cementing the the existing system that is in New York state right now, especially in New York City. Yeah, I haven’t thought much and I should take that up, like So how much does it cost you a pair operationalize. methadone clinic versus buprenorphine provision. But I also understand to an extent, right, why you have if you if you need methadone, I suppose if you need methadone, and you need to show up to a clinic every day, methadone is a full agonist, and there is a risk of overdose. And so the sorts of provision, some of it may be too much. But some of it may be like rationalize bubble, but as long as methadone and buprenorphine as are equally available, I think that this sort of notion of opportunity of choice for patients doesn’t necessarily exist for black and Hispanic patients, especially if they’re low income.
And just to be clear, so to the listeners, you’re a medical student, I’m an otolaryngologist, neither of us have expertise in the differences between these two medications. So you know, I think we will we I think we should change focus a little bit. Yeah.
Maybe I got too in the weeds.
On addiction, by the way. Oh, so you do
that okay.
Yeah, I got to have become an addiction researcher basically, after having learned so much from Dr. Hansen. Yeah. So I should have probably said that
that is something that allowed you to kind of springboard into that area. Yeah. So something that you are and also are an expert right now is being a student. And so one of your episodes was a big hit your way to success. And I just thought that that term was, was interesting, right? And really telling of, you know, standardized tests. So right, what does that mean? And what is what are some of the things that you guys talked about on that episode?
So big idea way to success? It’s kind of a joke, like an online running joke back that’s been going on for a while now. And so if you google bigger your way to success, there’s like a list of a bunch of racial stereotypes that are known to show up on the US Emily’s standardized tests both step one and step two. So, for example, you know, if you get like a question about a young, I don’t know, 35 year old black woman who’s coming in with a dry cough You don’t even need to read the whole paragraph you kind of know that oh, this is gonna be about sarcoidosis. Right? Yeah. So, there are several of those. You talked about Tay Sachs disease earlier, when you know like you just kind of them when they tell you Oh, this person is like French Canadian or like those stereotypes are very much ingrained in both in how medicals our medical curricula are designed, but also ultimately how the standardized test I don’t know whether it’s kind of like to give us freebies. But at the end of the day, it I feel sometimes it can contribute to reinforcing stereotypes such that you know, some diseases may end up being under diagnosed and subpopulations because we don’t always even have the presence of expanding our differential diagnosis just based on this kind of statistical discrimination. Oh, yeah. You
don’t know what you don’t know about this person and exactly what example my wife’s father is black and her mother is an Ashkenazi Jew. So to look at her, you know, most people look at her and think she’s black. Some people look at her and think she’s Dominican. But most people look at her and they think black. And so, you know, she could be a carrier for Tay Sachs. Right? We were tested, we have three kids. And so we she wasn’t. But like, if you were looking at that multiple choice test and looked at her, right, you would not test this person or take socks, that’s not going to be the way you’re going to answer that question. So right, you know, so you don’t know you don’t know what you don’t know about this person’s history.
And, and my advisor, my academic advisor, tells a story of a patient who had cystic fibrosis black kid, and this isn’t a day where sometimes like x rays would be printed out. And four weeks, no one would figure out what’s going on with this kid. And someone else looked at the X ray without knowing the history without knowing this patient’s history and was just like, Whoa, who’s the kid would see just by looking at the X ray, and it hadn’t crossed the medical you know, the medical teams mind at the time because it’s like, oh, you have a black kid with a lung issue is no one is thinking about cystic fibrosis because we it’s so ingrained in us Think CF is for white people a sickle cell is for black people, sarcoidosis is for black. That’s kind of those are the stereotypes of medical licensure exams. And my guests on that episode is Dr. Jenny sighs. She’s an emergency medicine resident at Yale. And I met her while she was still doing this work as a med student as well. So she’s done some studies that kind of fine comb through the curriculum of the medical school over Bronwyn where she trained and wrote some papers about the need for introduction of critical race theory and a lot of medical school curricula, right thinking about how race is constructed, racism is constructed and how it affects disease and inequality and those types of things. And I think, you know, with that kind of approach, where we embrace the social sciences and what they have to offer medical education that we ultimately gain right from being just better trained physicians, but that’s basically what that episode was about. So before we move on, are
there are there any other particular lessons that you’ve learned from your episodes that you think bear mentioning there’s so many
more one more nugget. Well, so episode specific, I think my episode so I did two episodes about reproduction, especially black, you know, related to black women. And I interviewed a professor of bridges, garbage issues and anthropologist and Professor Robert doty. Robert so she wrote killing the black body. And he our bridges wrote are reproducing race and they both talked about ways in which the medical preparedness along with the instruments of the state and state by state i mean capital and state had this element of control over reproduction, especially off black women. So kRb just work at the time I interviewed her is centered around the experience of low income black woman on Medicaid in New York City who basically felt a lot that their experience seeking prenatal care was a lot more invasive, compared to the experience of women who are not on Medicaid just because a lot of the testing and a lot of the questioning and a lot of the things that are required a pregnant woman drink Natal care of mandated whereas it’s not the case for women who are on more, you know, private insurance and Professor Roberts work, you know, killing a black body and our compensation in general was about the criminalization of black women during pregnancy. And, you know, we talked about how, you know, during the crack cocaine epidemic, you know, black men were punished really harshly for using during pregnancy. And today, in the context of the opioid epidemic, some of the laws that were put in place during the, you know, around drug use during pregnancy, are basically now sort of like reverberating and affecting pregnant women who are using opioids. In fact, Dr. Bridges just wrote a paper in the Harvard Law Review about opioid use disorder of pregnancy, and how using drugs in this new context actually can erode one’s white privilege. So just fantastic work. I’m so lucky to have just been able to sit and ask them questions. Yeah,
it’s a great medium. It’s a great medium, it really allows us to put ourselves in some In front of some incredible people and their self included, yourself included
learner, or sort of Elon,
well, we’re all learners. We’re all there. So, okay, so one thing we’re going to talk about was your experience as a learner, right? So we’re going to talk about interpersonal racism as a medical student, and institutional racism as a medical student. So what can you tell us was let’s start with interpersonal racism? How does that affect medical students specifically?
So I think their interpersonal racism and med school as kind of twofold, both like experiencing it, and also witnessing it and by experiencing it, I mean, like, sort of, in one on one encounters with classmates, residents, colleagues, even lecturers and then witnessing, it’s so being wielded against classmates or even wielded against patients directly or indirectly. And so for me in med school, I’ve had Yeah, and they haven’t necessarily been like The most egregious forms of quote unquote interpersonal racism in terms of like what’s happened to me, but at the time some you know, it can feel like, Oh my god, I can’t believe this is happening. So a good example, my first year, Terence Crutcher among many black men were killed by the police. And you know, some classmates went to a protest. I didn’t go Actually, I had to get the VA and then come back to campus and the DS not not super close. So after they went to this black lives matter, rally, you know, in their white coat, as physicians often do when they go to political demonstrations, one of our classmates called, like, how do you call it like a panel discussion around should physicians wear their white coats to protest and it felt like a very clear direct attack on those of us who did go to the rally, but in general, those of us who support Black Lives Matter, it wasn’t like a direct like, you guys. Black lives don’t matter, but it felt that way. Right. It felt that clearly my class felt that even if I think like last matter, I need to know I need to leave stuff out before I come into Medical School or into the classroom or whatever and it’s in, you know, some of us don’t have that luxury, the activism that we engage in, or the advocacy that we engage in isn’t only about our patients, it’s like also about ourselves, right? Because like, when I walk out of the hospital, I think that white coat off and I’m just another black dude that the police can pull over. And, and that was probably one of the bigger things that I felt hurt about in that school as a first year. But, you know, the worst things that I’ve seen are more so around, you know, witnessing issues related to patient care, you know, seeing patients being labeled as quote unquote, medication seeking even though how can you tell we can’t read people’s minds, you know, and it often happens around like mission was in a sickle cell crisis. Sorry, before
you move on. For that point. I just thought, you know, as, as medical providers, right, I know. That term. We’re doctors, right, but we’re under the umbrella of providers, doctors, nurses, and other other health professionals, right. Our goal is to help people people live longer, better lives, right? And so something that plays an incredibly important role in living a long healthy life is social determinants of health. Right? that determines health outcomes, much more so than the Lipitor that we’re prescribing the hydrochloride size for your blood pressure, right? So by wearing your white coat to a rally to help improve social determinants of health, it seems to me a completely appropriate thing to do. Right. What was the counter argument to that? What is it that you heard that said that someone said, why you shouldn’t be doing that? Is it because it’s political, and you should leave politics out
of medicine? Right. So that’s one of the arguments that were made. And I think, you know, race or racism kind of ruffles, you know, still still today ruffles people’s feathers in ways that Other political issues don’t nearly as much right? I have never. So as a med student, I was also part of this coalition. And that was for saving the Affordable Care Act. I did phone banking for funding for chip, you know, children’s and insurance. No one’s ever said, Oh, leave your white coat before you go outside and do as a demonstration for the Affordable Care Act. But the way insurance is decided in this country is the heavily political issue. But I think there’s just a discomfort, right with a lot of non black people when it comes to embracing the notion of racial justice that led to some people feel like Oh, we got to have a conversation about this. I don’t feel comfortable with people wearing yellow gear, or their white coats at this demonstration. And rightfully, some of us were like, Are you kidding me?
Yeah. Interesting. Interesting.
I mean, someone even suggested, well, what would you say if someone is wearing their white coat to a neo nazi rally kind of making the false equivalence between neo nazis and the Black Lives Matter movement, which is
Yeah, I don’t even know what to say about that specific comparison. But yeah,
so I think the counter argument would be, if this person did that, there would have to there would potentially be consequences, but they can find feel free to do that. However, if you are seeing doing it, then, you know, and you’re in a program, and your program director sees like, there, there are ramifications to to doing that. And I would hope at least that there wouldn’t be ramifications to doing that in something like blacklivesmatter. Right.
And I think a ton about you know, the first do no harm, which is part of our posts, right. And this debate of physicians engaging with social responsibility and politics is as old as like the 1800s right when Barca was super engaged in Germany and and like, you know, pushing the government to create a program for compulsory needs expectations, right. That’s how we found out about chicken Some may argue, oh, well, your job as a doctor is in a clinic room and not outside. But truly, it’s everywhere. It’s no, no, but here’s,
here’s, here’s what it is. If they agree with you, then it’s your job to be involved in advocacy. And if they disagree with you, then usually the white coat at home, right? It’s just that that’s just what it is whether they agree with your whatever your you know, it’s the same way when like someone in Hollywood, right says like, you know, Trump is terrible, or Trump is amazing. And then, you know, if you just if you agree, you’re like, yeah, I totally agree with this person. And if you disagree, you’re like, is singing or whatever. So I think I think the same thing applies here. Right? If they agree with you, and they think great. If you wear your white coat, then it should it gives you some more like authority and respectability of the institution that you can carry with you to this rally. And if you disagree, then you’re you know, abusing your privilege as a medical student. And yeah,
it’s
my personal take. Okay. So we’re also going to discuss studies that you’re familiar with that focus on racial climate for medical students and residents and fat and faculty. And you we’re going to we’re going to discuss that as well as disparities in grading and career advancement. So, so what can you tell us about just in general the the racial climate for, for trainees,
right. So I think in general, you know, medical students, especially those who are underrepresented in medicine, describe what seems to be a tense, often tense racial climate and medical school and that, you know, not necessarily feeling supported as minorities, you know, feeling higher burden when it comes to contributing to educating our peers on matters of health equity or health inequities, and facing kind of a barrage of microaggressions from tears faculty, residents and whatnot and
some study what what’s a microaggression? Because some of our listeners might be familiar With that term Good point, I don’t
personally like using the term microaggression. But it’s it’s, it’s
just use it for now you got it I know.
So microaggressions are, you know, considered to be slights that are typically not intentional based on a marker of difference that you may carry, but that land within negative impact and can leave like a lasting effect on the recipient of the microaggression. So for example, something that’s as commonly told to black people is like, Oh my god, you sound What is it? You sound so articulate, right, which oftentimes is rooted in the assumption that you you’re not supposed to be articulate or that you don’t, you know, that you’re not supposed to sound educated as a black person, even though you may be still like in higher education and a lot of about microaggression is basically based on prior experiences as the recipient and also just having faced them over and over and kind of what the expectation and interpretation is. And and I guess they’re called micro only if the person who is the perpetrator didn’t intended to offend it, but there’s so much right. So
so they intended to offend that it’s a macro aggression. Oh, yeah, it’s
a total aggression.
Micro is based on the intent, not how it was received, like if I bother you a little makes it a microaggression versus my value on. It’s the intention of the person making the statement.
Right. I think that’s that’s my understanding of the way that psychologists who, who coined the term described it as Yes, yeah. Oddly enough, though, you know, that there isn’t. I mean, maybe there is and I’m just not as familiar but like in the, in the, in the literature regarding medical students experiences, there’s a there’s quite some about, you know, microaggressions but I guess that’s in part because those are way more common and be sophisticated, highly educated settings, right. People don’t just call you the N word. You know, by the time they’ve reached medical school, they know better or you know, they mean like this Things that are more macro and that they happen like middle school or, you know, like, happen a little less commonly and in, in higher education and perhaps that’s why there’s more of a focus on micro aggressions. That being said, though, there are some macro aggressions that’s still happening.
And then how does that lead to? How does it affect outcomes like grading or career trajectory?
So I think microaggressions by themselves, you know, the climate in general and medical school has an effect on medical students like mental health, you know, and, you know, feeling burnt out and sort of like increasing rates or feeling socially isolated and not supported. And so you can think how that may have an impact on one’s ability to or just like one’s even will to to do as well as they may have meant to initially from that sort of like intrinsic element of the experience as a medical student, but there’s also when I think about grading, what’s been What’s out there literature wise is that they are disparities and grading. And they’re more so rooted in the perception of those who do great medical students, because a lot of these studies basically kind of control for all the other things that are more intrinsic to the students like sort of like performance, right? How did you do on step one? How did you do on those kind of like objective metrics that have nothing to do with a third party deciding whether you get honors versus high pass or pass and for example, the comments that students get in their in their evaluations oftentimes are racialized and gender. So there’s a study that was done at Yale by one of my mentors, my mentor came in a few of my interests, actually, Dr. Wright and Dr. Smith and the rest of their team, there’s a large team that looked at letters, how do you call this MSP The, the big letter that goes out when you apply to residency? I’m not there yet. And I look at comments from the from tertiary grades, and the most, the letters that are more likely to have those superlatives. Not excellent those Kind of terms are way more likely to go to white male medical students and black male medical students are more likely to be sort of just labeled as competent, maybe like hard worker, but never those superlatives that program directors tend to look for. And then women get labeled as carrying, you know, kind of this sort of kind of benevolent sexism that often shows up where the qualities of the students are highlighted based oftentimes on race and gender. And then when you think about career advancement opportunities, like la Alpha Omega alpha, right, lucky, I mean, I don’t know whether that’s lucky or not, but we don’t have a chapter on my medical school. But the same team that did this study on MSP content, looked at resident applicants that that submitted applications to Yale, so something like maybe 15,000 medical students from across the country and they found that when you control for grades, step one scores like you know, all the kind of the semi objectives, I don’t really think they’re all that objective, but the number of things Black and Asian medical students are six times less likely still to be inducted in AOA up their homes, you know, their home institutions and, you know, some program directors filter applications by a by, you know, elite status. And it’s a huge thing to think that it has six times, you know, my take on that is there are people that are eligible on AoE, typically based on their, I guess, ranking in their medical school class, like, you know, are you in the top, whatever quartile it isn’t different institution, and then there’s a body of student members that that often have to vote on, on induction membership, whatever, based on, I don’t know, some criteria set within the school. And, you know, you can imagine that some of it is basically kind of a popularity contest, and it’s kind of telling that those were way less likely to make it into a way are black and Asian students. You know, kind of like least likely to look white, I guess I’d like to present or potentially present us like, it’s kind of my read on that. If you ask me. That’s kind of racist. And the stuff
I don’t know if kinda is
in that statement. Yeah. So So what you’re saying is that it affects your grades. Right? Yeah. In that and that can be that’s been studied for, right that’s what you’re saying is, is that if you blind, you know, if you blind someone, to, to what this person looks like, as much as possible by just doing the objective multiple choice tests that we all have to take and we’re all then it really the data really seems to speak for itself and so that I think if you turn if you think of things in terms of like, I heard actually Jamie Foxx once referred to himself as the arrow and his grandma was the bow so I thought that was a great analogy for the way that my wife and I are raising our kids we just were aiming the bow and the arrow is gonna go or the I was gonna go. But if you’re if your career trajectory is like is the bow pointing in a certain direction, if you’re already starting at a lower angle, because this is good Preventing you, now you’re getting lower grades. Because you’re being described this way your letter of recommendation aren’t as compelling. You’re not, you’re less likely to get an eo, this is talking in terms of career trajectory, where you’re going to end up 2030 years from now, you’ve already attained the bow in a different direction, right? And there’s no quantify. I mean, there’s like no exact way of being able to sort of quantify that, I guess, unless we were to kind of look at things in the perspective like a prospective cohort. This I mean, there is a chord out there. I don’t know what questions they asked the participants, but the change does a lot of studies on like bias and microaggressions and whatnot. Amongst medical student It was a cohort that initially enrolled like 5000 med students across the country, and they followed them and I think they’re now 30 are residents so I’m, you know, I’m curious to see when they’ll make some of the some of the questions that they’ve asked available and, and and how far one could ask like, oh, what, how did the trajectory of some of these students change based on their experiences with with racism and whatnot in med school. And I’ll give you an anecdote in terms of both the grading and some of the, you know, the gatekeeping structures that may exist. So I had an experience where I that’s so rare, I had a black male resident in a longitudinal clinic. And I was and, you know, supervised by an attending who was white, and during that time, it was a weekly clinic, and most of the time on collections, you know, you spent a lot of your time with, with the resident and not so much with the attending, and this resident at the end, and we have great, you know, great working or poor, you know, every day at the end of clinic, would maybe spend 15 minutes sorting out the attending. At the end of the clerkship, this resident will be a super long, very good about ration. I mean, I was beaming with pride, even though he submitted it late, and they’re attending on his end, nothing in the part of the evaluation that’s supposed to go in my transcript, literally nothing. So he saw nothing that’s worth talking about me and what would end up being my MSP letter. So I email my clerkship director, because this resident had turned it has turned his evaluation late like, Hey, you know, do you think we can also add the residents evaluation just for more text in my eval? And you know, it, this is a rotation that are honored anyways. And I did really well, overall. So there was no, there was no grid issue. I just wanted those comments to also appear. And the response was, well, for that specific clinic, we really just wanted comments from the attending and not so much for the residents and needed so well anyways, that it doesn’t matter. Now, imagine if I didn’t do well, and that the structure is that we just want comments from the attending and the attending pays me no mind, but the one time that I do get a black president has evolved doesn’t even make it, you know, into my transcript that’s sort of like dwindling representation amongst who supervise us has an impact ultimately on whether what are you know, what are, how do you call that what our msps are tracking So I have are going to look like I spent an entire year on the war. I never had a black attending who was going to give me a grant. I had a few black presidents. You know what I mean?
Yeah, you know that that sums it up in terms of your experience. I don’t know. Sometimes I think it’s very telling in terms of your experience, right? One or no black attendings, a few black residents. And so this is what this is what your experience is like. And as opposed to students of other backgrounds who are able to look and see people who look like them in all sorts of specialties. So so when you when you see, let’s say, you did have one, black attending, right? And how do you think that would affect your decision with regards to specialty Do you think that would in that would alter your decision making I mean, it’s hard, because you’re, you’re, you’re it’s hard to take yourself out of the situation and look at it objectively, but, I mean, generally, if you’re on a rotation, and you’re Your attendings and residents are jerks, you’re less likely to go into that specialty, you’re not gonna have a good experience. Whereas, even if it’s maybe not the right fit for you, if you have a specialty where, where you have a great time, because you’re getting along with everybody, you’re more likely to go into that specialty. So what about your situation where there are very few people who look like you? And yet, you have one, maybe two and other specialties? How do you think that will alter your decision making in terms of what you ultimately choose?
I think for me, I probably would end because there’s like I said, there are so few and just about every specialty, right? So it’s so the bets are like almost non existent. But I think it would make the experience better in that one. As a student on that rotation, I maybe I’ll spend a little less time worrying whether the feedback or criticism that I’m getting from the attending is like from a place of assumption of inferiority that sometimes we just kinda have to wonder like, Oh, this is attending thing I’m done, right? Like, that doesn’t tend to be the case, when you have another black attending that may hold you, they may even be I have just from having conversations with other peers that sometimes a black attending or even resident may hold you to a higher standard because they want you to, there’s this link fit in making sure that you do well. And we’ve all kind of been, it’s all been ingrained in us that you have to be twice as good to have it half as half as good. That’s kind of like the saying that just about every black parent tells their child so I don’t think for me, at least it would like make me want to go into a specialty versus versus another. But I think for some people, though, it may in that being told that you are welcome in this specialty is very meaningful, right? And that is indeed perhaps more likely to happen if the time that you attended and that specialty. You had a mentor who took ownership of you as a student and like mentor to you. Yeah, there’s some specialties out here. Even if everybody was black I wouldn’t go into.
And whenever I have a student rotating with me, one thing I always tell them is, it’s the most important thing is to find out what you don’t like.
There’s a bunch of stuff out there that you’d be happy doing. Just make sure you’re not in one of the ones that you won’t be.
Yeah. So I think the impact is not so much of a, seeing a black attending is going to make somebody go into it, but guess is not having a black attending and then also not being welcomed or even not being being told that Oh, you’re never gonna make it or people not showing enthusiasm or not mentoring you the lack of black attendings as opposed to the presence of them. I don’t know if I’m making a clear argument here that can impact you know, those trajectories is my guess. I mean, there isn’t often an assumption that Oh, minority medical students are aware and more likely to budget primary care without investigating the root of it. All right, like Sure, yes, we are more likely a bunch of primary care but nobody knows. Whether when we came into med school, whoo, half of us were like, Oh, I’m gonna do plastic surgery or I’m gonna do neurosurgery or whatever, right. But as I would like for it to be studied, whether during those clerkship experiences the, you know, experiences of not feeling included, being actively or passively has made people more or less likely to say, oh, bump that I’m not going into insert specialty, because, like you said, those people were jerks, or those people didn’t include me, or those people just never saw me as fitting with them. My opposite one of my optical faculty members, like y’all, she’s a black woman, Dr. Kristen, why will, she said when she was a resident, you know, she is a tiny black woman, and everybody who walked in who was a tall white man, they would say, Oh, he’s gone. And he just looks like his daughter right now. And she said, I’m going to retina but people never ever supported the idea that she would be a retinal surgeon. But she said, I’m going to do it from an intrinsic motivation. And she did it. She’s a retinal surgeon but barrage with these assumptions on all year. You’re just you’re just going to be a generalist, although it’s obviously it’s great to be a generalist, regardless of being as in primary care or like a generalist and that surgical specialty, it almost kind of robs you of your dreams sometimes, you know, to not be told that you can do it, you can also do it. Yeah.
Well, Max This is this would be a great conversation. I really appreciate you taking a lot of time out of the busy students schedule and away from your studies to have this conversation and and to put together the podcast because it’s clearly clearly a lot of very important conversations that need to take place. And I’m, I’m so glad that you found this platform. So where can people find us? Where can people find your podcast? So the podcast is flipped a script. If you can find it on iTunes, Spotify, SoundCloud, if you search for flip the script, yell, I think there are a few things that show up as flip the script by itself. So it’s the one with the El blue yell logo. It’s the broadcast center that helps me with hosting. flip the script yell, it’s easy to find. On on Twitter, the handle is flips pod. Yeah, so check it out. So we’ll include links to all that in the show notes because I certainly had trouble finding when I just looked for flip the script and then the done popping up and it didn’t make any sense I was looking for Yeah. So now I find,
yes. Well, thank you so much for the opportunity to have this discussion. I really appreciate it.
That was Dr. Bradley Block at the physicians guide to doctoring. He can be found at physicians guide to doctoring calm, or wherever you get your podcasts. If you have a question for previous guests, or have an idea for a future episode, send a comment on the web page. Also, please be sure to leave a five star review on your preferred podcast platform. We’ll see you next time on the physicians guide to doctoring.
Transcribed by https://otter.ai

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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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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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.

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.

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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

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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

 

Overcoming Our Racial Biases to Better Serve Our Patients

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

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

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

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EPISODE TRANSCRIPT

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

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

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

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

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EPISODE TRANSCRIPT

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

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