Bradley Block

Compassion Fatigue and Assertiveness with Nathalie Martinek, PhD

Nathalie Martinek, PhD is a recovering developmental and cancer biologist who transitioned out of the controlled environment of the laboratory into the messy world of human behavior and relationships. She continues to apply her critical and objective lens honed as a scientist to understanding drivers of human behavior in the various relationships that exist in healthcare contexts to discover what prevents and promotes wellbeing and professional satisfaction.

Dr. Martinek is a speaker, listener, coach and consultant who facilitates training programs and workshops worldwide for diverse health professional audiences to enhance their capacity for human connection, abuse prevention and healing through cultivation of psychologically safe and stable therapeutic partnerships. She recently published her first book, The Little Book of Assertiveness, to provide scripts for shifting power dynamics in professional relationships to embody the qualities of a respectful and compassionate healthcare culture that enables everyone to thrive.

We discuss how to be assertive in a hierarchical environment like medicine without offending your superiors – and it starts with being curious. We then pivot into discussing compassion fatigue, first by defining it and then by exploring ways to interact with patients in a way that doesn’t end with us unnecessarily burdening ourselves with no benefit to the patients. We then end with some self-care practices that allow us to process those burdens.

Find her at drnathaliemartinek.com

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EPISODE TRANSCRIPT

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Dr. Natalie Martin Nick is a recovering developmental and cancer biologist who transitioned out of the controlled environment to the lab and into the messy world of human behavior and relationships. She continues to apply her critical and objective lens honed as a scientist to understanding drivers of human behavior in the various relationships that exists in health care contexts to discover what prevents and promotes well being and professional satisfaction. Dr. Martin Nick is a speaker, listener, coach and consultant who facilitates training programs and workshops worldwide for diverse health professional audiences to enhance their capacity for human connection, abuse prevention, and healing through cultivation of psychologically safe and stable therapeutic partnerships. She recently published her first book, The Little Book of assertiveness to provide scripts for shifting power dynamics and professional relationships to embody the qualities of respectful and compassionate healthcare culture that enables everyone to thrive. We discuss how to be assertive in the hierarchical industry. That is medicine without offending your superiors. And it starts with being curious. We then pivot into discussing compassion fatigue, first by defining it. And then by exploring ways to interact with patients in a way that doesn’t end with us unnecessarily burdening ourselves with no benefit to the patients. We then end with some self care practices that allow us to process those burdens.
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.
Dr. Natalie martynuk. Thanks so much for being on the podcast.
Thanks for having me, Bradley.
So let’s start with your origin story. What what’s your PhD and And what was your thesis?
My thesis so this is a really awesome title. It’s spark is required for basal lamina stability by mediating type for collagen deposition during embryonic development of just soft lemme Lana gastric.
Oh, Monica master mind my favorite my old friend. Yeah, that sounds that sounds really interesting and really that tends to be the theme of this podcast is everything that can be learned about the basal lamina of a I’m not even sure if that’s what you said of the dressage. That’s right. So what what does that make your PhD in? You are a developmental biologist,
development biologist, so I was really interested in understanding the unsexiest the least sexiest part of a body, which is the connective tissue, the extracellular matrix, all the environment outside of a cell. So while everyone’s studying inside, what’s going on inside the cell, I was looking at what’s going on outside of the cell that is eating influencing how cells behave, how they move, how they invade. And that led into my postdoc in cancer research. And the reason I was interested in that is because it’s a less controlled environment, you know, whereas you’re working in a cell, you can kind of manipulate the proteins being made, or you know, the enzymes, and you can see its effect of what’s going on inside the cell. Whereas what I’m interested in what I was interested in is looking at what the cell is producing how it influences its behavior, as well as the development of the organism. Yeah, so that’s basically where I started and I was looking at the cells, the macrophages of the of the fruit fly, which are involved in surveillance and removing pathogens and other things that invade that you don’t want in your body.
So is that what you’re working on right now?
I guess yes and no, biologically No. So where that led to was trying to understand how to relate this the cells that normally move around the body play a role in the music system monitoring surveillance protection against, you know, my microbes and pathogens into still using your software to study tumorigenesis. And so is looking at what how do cells move from an original location and invade into tissues and start to migrate and take over the body basically co OPT the defense system of a body of an organism for its own means of survival. And so while that was occurring, during my postdoc years, I started to become very interested in the conditions within a workplace environment that would enable certain behaviors to start to manifest as bullying or to, you know, spread around an environment and create a sort of toxic culture. So what I’m studying biologically was mirrored mirroring or mirrored in my external workplace environment, and that became more of an interest to me.
Oh, I was hoping that that was the direction you’re We’re gonna take this in, because I was hoping this wasn’t gonna be an entire podcast about Drosophila. And knowing you and what you’re doing now, I was like, man, I hope. I hope she ties this in. Oops, didn’t go back to the lab, and she’s gonna be talking to us about pipetting. Again,
no. Okay, looking at the conditions that exist that promote or prevent certain behaviors from existing and amplifying what what made you make that transition suddenly different things? burnout is one of them. You know, and the way my experience of the way I experienced burnout is that when you’re working in an environment or in a, in a in any place where you believe that it’s the right direction for you based on your training and education, what’s expected but yet it doesn’t speak to your heart. It doesn’t address some of your major interests. And what else you could be doing, the longer you stay in that situation, the less I guess the more energy is required in order to make maintain that, that makes sense. So you’re not actually living a fulfilling, at least not your work life. And it’s and it seems to spread into all your other parts of your life.
Well, sometimes it seems like it’s, you’re like a hamster on a wheel, and you’re kind of that idea of publish or perish, that you’re almost doing it for someone else, not for yourself, not for your own interests, not for not for the research, but more like you have to produce something, just in order to keep your job and keep your grant. Even if it’s just kind of like paying lip service, not not what you’re, you know, not not that you’re trying to answer a question.
Yeah. And when I start exactly so when I started to think about well, why what’s not right, what’s not going well here for me why, you know, on the surface, this should be what I’ve always wanted, interrogating the mysteries of life using fruit fly and biology. And then I was looking at the culture around me and seeing, you know, the effect of being an environment like that. on me, I was turning into someone I didn’t like in order to survive. And that that type of pressure and environment, looking at the way we address illness and try to get a better idea about the mechanisms behind disease. And we’re using a lot of data or theories or beliefs that are quite biased and, you know, got to the point where I’d be listening to someone’s talk or reading a paper and I’d be able to spot the unconscious bias very early on, and would poke too many holes within their story that I couldn’t listen to anymore. And after a while, I’m like, if this is my, if this is my experience, why am I still here? The other thing is we’re looking at human disease, you know, cancer, which doesn’t happen in a fruit fly naturally, or quite rarely, but doesn’t have the same impact. And we’re trying to understand the mechanisms of this disease in the fruit fly, but we’re using almost assumptions that by understanding the mechanisms in a fruit fly, we can apply it into the human experience, which we can’t because only humans are the only organisms on the planet who can make meaning about their life experience who, you know, we’re not looking at the impact of trauma, intergenerational trauma, community healing, we’re not eight emotions, we’re not able to study that in the controlled environment of a lab or in a tissue culture. So I started to become disillusioned with what we’re trying to achieve and whether or not what I’m doing in the lab applies to that patient that was in the floor underneath me, you know, in the in the floor down with their chemotherapy treatment, is this what they want? Is this the kind of research that they’re wanting us to do? Is this really what’s helping them? And the answer kept coming back to me No. So after a while, it was just I recognize that this is not ethical or within my integrity to continue in this way. And I had to make that tough decision to hang up my lab coat for good, at least in that setting.
So it sounds like you were so distanced from the intervention itself, like, you know, the research that you were doing was so far down the road from the eventual intervention which was then you know, distance very far from the patient itself. Then it was hard to, to continue doing that work. And it was almost like you were in the academic rat race.
Totally. No. And, and it felt a bit exploitative because we’re, we’re getting public funds, we’re using public funds. We’re justifying our, you know, the rationale for our research by saying this can potentially have some sort of direction towards a cure. But we don’t know when we’re kind of building up hope. And I, you know, I recognize the importance of that, but it’s like, it didn’t feel authentic, that we’re actually caring about the patients that were in the same hospitals or Research Institute. We weren’t actually talking them to find out what’s meaningful for you, what is it that you need us to be studying in order to support your experience? So it just felt so removed?
So then you pivoted and one you wrote a book on assertiveness, which I would imagine a lot was taken from your experience in academia and in that lab setting and then you also To speak on compassion fatigue. So, first, with regards to the shortness tell us just tell us a bit about the book and your workshops.
So assertiveness, you know is this topic that I didn’t anticipate would be this common thread running through my life since I was a kid. I noticed over the years, especially as a Canadian having moved to Australia, you know, there’s so many similarities between these two countries. So there’s quite some massive differences. And I noticed the one difference is that people were not as upfront with the feelings or their truth being honest. So you wouldn’t know where you stand with everyone. Everyone’s working hard to make sure everyone you know, looks good. Feels good. In which country? Australia In Australia, okay. Yes, sorry. And no one would really raise issues. It’s only that you know, you only discover that there’s an issue when it just becomes conflict, like boom, out of nowhere, and then it would make me think about why why that is. Why are people so afraid to speak honestly about their thoughts and feelings or ideas. What are we so afraid of, and it wasn’t quite my experience in Canada, people would be upfront with where things stood. And you’d be able to, I don’t know, work together. And maybe it was the environments that I were that I was in. But I found among really educated people, and this is not just in Australia, this is widespread. And this comes from doing lots of coaching and training work with physicians and other health professionals among health professionals. The common theme is that people are too afraid to challenge ideas, especially the ideas that come from someone who’s perceived as an authority figure, or someone who’s more knowledgeable than that than they are about a topic or an area of expertise. And so they’re more likely to be compliant and listen, or be combative in order to push their, their viewpoint across instead of challenging. And then when I started to, you know, go deeper into it, the skill involved in challenging an idea and learning more about it or getting to shift perspective is assertiveness, it became clear that we need some more information about what assertiveness could look like that is not combative, aggressive, trying to control a situation to get the outcome that you want. It’s looking at what are our values? What do we really want? And what is best for the US, not just me to see you, but we
Yeah, medicines very hierarchical, right? Like, you’ve got your medical students, your residents, your fellows, your attendings, you have the nurses and the nursing assistants, you have, you know, this is a complex system but with a very clear hierarchy. So, it can be challenging to assert yourself without being disrespectful or, you know, without fear of the repercussions of at least being viewed as disrespectful. So what recommendations do you have for within within that hierarchy for asserting ourselves, right? If we See, if we have a quiet if you’re a resident, we have a question for attending. If we think that a patient’s we should be paying more attention to lab value, or we think that the surgery may not be the best thing for this patient. You know, what, what recommendations do you have for asserting ourselves without being disrespectful?
Hmm, it’s a good question because I think there’s this assumption that assertiveness comes with disrespect that we can’t be assertive and respectful at the same time. Whereas my version as I described in the book is extremely respectful. It’s acknowledging the role that we each play among in a team that we each have an important role, and they’re all required in order to fulfill a purpose or to achieve You know, this desired outcome for all of us, including the patient, so as best as we can, so assertiveness, the way I use, it is about applying inquiry or curiosity. So we all have different assumptions. We all have different beliefs, we all are, view our roles differently and each other’s roles differently. So how do we know what we’re thinking? Unless we ask the question, tell me more. Tell me more about what you understand about the situation, or you help me understand what you mean by that. So I’m on the same page as you. So we have to recognize everyone’s role is important. Therefore, we should be respectful that we don’t each know everything. There’s something that I can learn from someone else. And I want to learn from you in this moment. So please help me understand. So I see that just the asking, asking questions instead of expecting to know all the answers, because that’s part of the culture as well that you just should know. And that’s a sign of weakness. If you ask questions, assertiveness kind of breaks through that and goes, I don’t have all the information. I don’t know everything. I’d like to know what you know, please teach me please show me I want to, you know, you have some wisdom that could benefit me and us I’d like to know it.
So it sounds like you would maybe rephrase the question as if you’re acknowledging that you may be wrong. So like, if you’re questioning the way a surgeries, the plan for the way the surgery is going to be done, it should be you think it should be done. B. And the plan is to do it a, you would more ask it assuming that A is the correct way to do it, but you think it’s B. Right? So like, yeah, the assumption is that the person who is asserting themselves doesn’t, is actually incorrect. But they want to know why. You know, why? Why answer a is actually correct. So that’s one way that you’re being deferential within the hierarchy. But at the same time, maybe, you know, that’s the way that you’re questioning the authority.
Yes, you’re not coming across as I know better than you and you must be wrong. And I’m also not coming across as I’m wrong. I’m not making any assumptions. I’m just saying I’m, I’m wondering about your plans, please describe them to me because I want to make sure I understood them because I may have missed something. And that way I can ask questions as to, you know, explaining why you’re doing it that way, not because I think you’re doing the wrong thing, or I don’t trust your judgment. I’d like to know. I’m curious because it’s part of my learning. It’s coming from this place of humility, curiosity. I want to learn more. I want to learn more from you.
So that if this patient were to walk through my door, I don’t know if I would have made the same decision. How did you arrive at that decision?
Yes. Okay. So share your thinking process behind it. Because I’m, I want to, I’m curious about how you approach a problem or you approach a situation and it’s, I’m curious to know if it’s the same as an as a how I would do it. It’s like, it’s like that just the idea about learning. I’m here to learn.
Are there any and those individuals, right, that’s what their primary role is, right? They’re apprentices so they’re, they’re likely to learn Yes. Are there particular phrases that you found useful? Or the opposite and any phrases that that are particularly toxic that we should avoid,
or anything to do with feelings where you’re trying to describe someone’s feelings. So when you say, you know, when someone’s expressing something and they’re coming across as little agitated, I see you’re really agitated. Or don’t do that, because you’re just gonna tap into their agitation and amplify it. It’s also kind of suggesting you understand their experience better than they are, when you’re pointing out their feelings. You know, the other way of doing that is I can see that there’s something that’s there’s an outcome here or there’s something that happened, that wasn’t what you expected. Can you tell me what’s going on? You know, what’s happening right now. So that’s what I call a safer way less emotive, potentially less condescending sounding, even if that’s not your intention. Another thing is, I’m sorry, you feel that way. You know, if you said something or did something that was the right thing in that situation with that other person. You’re not taking responsibility when you say I’m sorry, you feel that way. I’m sorry. That what I said was hurtful or I’m sorry, that what I said, didn’t land? Well, that wasn’t my intention. Let me try this again. You know, that’s taking responsibility for the impact you have on someone else rather than I’m sorry, you feel that way. Which is pretty much saying, Yeah, it’s like, your problems, you know, your feelings, your problems. I had nothing to do with it. Like, that’s not.
That’s sorry, Your reaction wasn’t what I expected. Yeah, yeah. Okay. Yeah. But with regards to the the assertiveness, are there particular phrases that that would be useful?
I guess it depends on the context, because in the book, it’s talking about different situations and barriers to assertiveness, what kind of power dynamics are occurring, that makes it hard to speak up. Because, you know, like what you mentioned, there’s a hierarchy. But there’s also other inequalities that are present within any, any environment. We don’t all have the same starting line in life. So we can’t just go I’m going to stand up for myself because you could be making your situation a lot worse. If you don’t Understand the unwritten rules of the place. So it’s always about understanding what are the values that we each share here and communicating that I see that you want this best outcome. So what do we each need to do in order to achieve that? very proactive?
Alright, let’s pivot now to your other area of interest, the compassion fatigue, right, something that a lot of us in medicine are experiencing. We had a speaker on the podcast a little while ago, Dr. Tory SEPA, she’s a psychiatrist, and something that she’s written about is the fact that we give so much to our patients that when we get home at the end of the day, we really have nothing left for our family. So first, let’s define what is compassion fatigue?
Hmm, yeah, I’m interested in what you said. It’s like we give so much to our patients that there’s nothing left for us. That’s exactly it. We are giving too much and we’re not able to monitor the level of which we give and whether When it when it’s enough, you know when is our level of giving sufficient to get the job done or within the realm of our role and responsibility with that patient, which will differ slightly with every other patient, the definition of compassion fatigue. So there’s, there’s a few definitions out there, because it was coined in 1995. By figley. And from my own study of doctors and other health professionals over the year, I’ve come to a different definition, which is less about compassion and more about empathic overload. So compassion fatigue is not because we are being too compassionate, it’s because we’re not being compassionate. That’s the problem. So there’s empathic overload that resulting from an imbalanced emotional investment in helping another who we perceive to be in a more vulnerable or disempowered position coupled with an absence of self care practices. So we are dealing with this sort of power imbalance or this perception that this person is so needy that I need to get Give them more than I can then I have the reserves for and I’m not doing enough practices within myself to recharge my supply of energy. So that’s how I see compassion fatigue.
Alright, let’s unpack that. Let’s go to the to the first part. So the fact that we’re we’re feel like we’re giving so much to the patient that we have nothing left. It sounds like you’re saying the assumption of that means that they require so much of us, and often it is the case that they do not. Mm hmm.
Yes. So do you have an example of when you’ve given too much to a patient? What that looks like?
Well, I would think, let’s say I just I have to give some bad news, right? So the bad news could be, we’ve been monitoring somewhere to cancer and their cancer came back or if I have someone that, you know, we’re gonna have to do a biopsy on you because there’s a possibility that you’re right. That’s the big concern. That’s the elephant in the room is his cancer, right? So let’s just use that as the example. So right. So I see up to that 30 patients in a day. And so what might happen is I have someone in whom I have to give that type of bad news. And now I’ve got someone across the hall with a completely unrelated problem. And now I need to somehow reset, forget the patient whose room I just left because now their hand right there, I give them the news, they have a plan, they have a strategy, but I’ve explained everything to them, but, but that can be really emotionally fatiguing. So now I’ve got to be able to go and completely refreshed to this next patient who has a completely different problem from you know, starting from zero. So, you know, doing that over and over and over and over, is just, it’s really taxing. So, you know, that that that’s really the, the scenario that I that I think our listeners need to be able to work with.
Okay, so let’s let’s do this in a stepwise fashion because as you’re as you’re sharing the situation with the other contexts, you know, my mind is going off of like, oh, you’re doing it this way. And then you’re doing that way. And of course, it’s going to be texting, let’s go back here with the patient, you have the results of a test, and it’s not positive, you’re sharing the news with them. And they have, you know, an emotional reaction to it, I imagine some sort of reaction. And at the same time, you also want to make sure that they they’re informed about their follow up actions, their options, etc. And so you’re working hard, you’re working really hard to try to help this person. equip this person with what you think they need in order to feel a bit more in control. After having received this news.
They’re overwhelmed. They’re shocked. They don’t know what questions to ask. Yeah, they’re asking more logistical questions than anything else. like where do I go next? What’s the phone number? Is there parking there? Because they’re just so shell shocked about their diagnosis.
That’s right. So you’re already working. You’re already doing too much work there because what you have what is required, which Just the compassion thing. So it’s not saying any other ways not compassionate, but it’s like the right action that’s needed in that moment is giving them space to process that a little bit. And so what can happen is because we’re feeling really uncomfortable with their, the first of all that the information you have to give, how it’s going to be received by them, and then their emotional response to it. We tend to go into this, give information, I need to do something to appease my discomfort at saying something that upset someone else, but you’re just the messenger, you’re not the cause of their upset. There’s a situation that is happening for them, you’re reporting to them, what the tests have shown. And what is needed is to allow space for them to just receive that information and process it in that time and space you have with them in the way they need to. That might mean that they ask you questions, but when you start giving information, they have no room and capacity to do anything with it. It’s just more energy that you’re You know, putting out in order to somehow fulfill this kind of role or obligation you feel to make them feel better. But you’re working hard to do that you’re trying to force them from the state that they’re in, which is deeply uncomfortable for you into a different state that might feel more comfortable for you, even though it’s not wonderful overall. Does that make sense?
Yes. But, you know, if they’re, if they’re asking these questions, I don’t see. You know what I mean? Like, like, realistically, a lot of times they can’t they’re so overwhelmed with this new diagnosis with this new complete change in their world, right. It’s hard for them to process any information, totally. But they’re still asking you the questions. So I don’t see a situation in which I would redirect them and tell them listen, this is not the time for you to be asking those, you know, I, I’m not sure how to pivot from there.
Yeah. So it’s almost like you know, this is big news. And this may not be what you expected or might be what you expected. But we don’t know how we’re going to you know how how we’re going to feel about it in the moment? Do you need some time to process this? Do you need time and space? You know, I’m here to answer any questions you have. But I want to make sure you’re in a headspace where you can actually do something with this information. So you’re giving them permission to take space. The problem is you have, you know, I can only imagine that there’s short appointment times, or maybe there’s a longer appointment time if there’s test results to disclose, and that everyone is trying to the patient is trying to get as much as they can from you in that time. But like what you said, they’re not in any position to be able to process any event. So sometimes it’s a good thing to go, Hey, this is big, you might need some space. And I can answer questions after before you know, so that you can be in a different headspace where you can look at all your options and look at the next move you need to make and I’m here to support you with that. Would that be okay? Or do you have questions you want to ask now? So you’re giving them choices, and it’s less laborious for You know, and then you won’t walk away feeling like you had to do all this stuff in a certain ritual within a short period of time, and then have to move on to the next patient, you gave space you allowed, you allow the space for them to decide what they need next, which is I’m not saying that that’s not what’s done. It’s just a different way of doing it.
Yeah, that is more than I want to know, just acknowledging out loud, that this is gonna, this is a very overwhelming thing. And they might have difficulty processing it all at once. And so if you know, if they need just a little bit of time before we regroup and decide what happens next, then when they can do that, you know, at least in my practice, I could very easily just go, I could go see the next patient and give them at least a few minutes to kind of, you know, maybe they want to call a family member if they came close, or something like that.
Yeah, that’s right. So there’s ways you can manage the time. Definitely. So you see those options now. And it gives you room to breathe. It’s the you probably holding your breath for a whole day. Sure. If you’re going back to bed, Patience gives you the space to breathe with them.
So you, you know, we talked about compassion, fatigue and empathic. I apologize. It was
empathic overload. empathic overload.
So what’s the difference between compassion and empathy? Or, I guess empathy is?
Yeah, compassionate empathy.
So again, there’s so many different ways that I see people describing it. Empathy to me, is emotionally neutral. It’s the ability to basically attune to what someone else is feeling. It’s not about being in someone else’s shoes. We can never ever, ever be in someone else’s shoes. We have our own experiences, our own ways of perceiving the world. We can’t actually enter into someone’s shoes, but we can imagine what it might be like for them to to experience the bad news or, you know, experience living with cancer experienced an illness. We can imagine it and we can also be, we can also appreciate how they’re using their resourcefulness to live with With it, to deal with it to manage it. That’s empathy. It’s not about feeling what other people feel. But because we are emotional beings as well as you know cognitive beings, we can actually feel in our bodies, what people are feeling. I know for me personally, the more time I’ve spent working with people I can feel in my body where they have pain. So I already know where their pain is, before they even disclose it to me that we could start to believe that’s our pain. If we didn’t know better, we didn’t know differently. So empathy is what connects us. We need that in order to build a rapport and trust in a therapeutic relationship with a patient or client. But what can happen is we can feel people’s feelings so extensively, and we can just dive into the their story of their suffering, that we fail to see all the other positive things that are also occurring in their life at the same time, we can fail to appreciate their strength in their capacity to overcome challenges that we all have and we can just see We’re the we’re the one that ruin their day because we gave them bad news, we put that on ourselves. And so we become overloaded by all those feelings, those negative feelings and we become, it can feel quite heavy. And if you’re doing this daily with so many different patients day in, day out, and not going through any sort of internal process or debriefing process or any sort of self care process where we can make sense of it and unload it from ourselves, we become quite exhausted very quickly. So let’s talk about the debriefing process. Oh, what I didn’t act that I didn’t mention was compassion. What is the difference? So compassion is recognizing that we all suffer and we all have joy. Just because you’re in the doctor patient doesn’t mean we’re so different in that way. We all have these feelings. We all have, you know, our experiences, so I can, I can appreciate that you’re in suffering right now. But you know, there are other areas of your life that are also joyful or pleasurable, that it’s not only about the suffering, and my job is not to make you suffer less than this moment or feel differently. I’m here to recognize that we all suffer, we all feel joy, and I can see them both with equanimity. And my role is to do what? To do the right action in this moment. So how, what do I need to do with this person who’s just received news that upsets them? That is compassion. Compassion is not making them trying to make them feel something different. Like what I mentioned before it’s holding it’s it’s holding space for them to experience whatever they need to experience right now. That to me is compassion. So that’s the difference between empathy and compassion. Compassion is like what I call love with action, check. It’s empathy plus action, his compassion, and empathy is just being tuned into their experience, whatever they’re what they’re feeling and thinking. And it requires some listening skills, some inquiry skills, so asking certain questions to get a better understanding of what’s going on for them and just being curious about that rather than feeling what they’re feeling and trying to make them feel something else.
So it sounds like the theme here is really giving the patient space either really giving them space or verbally acknowledging the fact that they may need to take some space and that’s gonna unburden us at least just a little bit. Definitely. What about the that debriefing that you were talking about? Can you elaborate on that?
Yeah. So I don’t mean the debriefing that occurs, if that can occur after an adverse event. I’m talking about just the everyday the stuff that weighs on us the things that we encounter on a day to day basis, you’re as a physician, you’re seeing suffering, pain, joys, everything on a day to day basis, who are you talking to about this because it can be burdening especially if something that you’re experiencing doesn’t make sense to you or you haven’t, you know, resolve it within yourself. We have all these unresolved stuff that we carry every day, unless we give a voice to it and, you know, debrief it, disclose it, offload it, it just stays inside us and it becomes again, quite heavy. So it’s having a trusted person in your life. Whether it’s a therapist, a counselor, appear, a colleague, a manager supervisor, doesn’t matter as long as you feel safe with them, and you trust them. And they’re not trying to give you advice, and try to make you solve the problem. It’s about holding space for you, to giving you space to disclose the things that are weighing on you. And through that process, you might develop your own aha moments. So it’s just again, give allowing yourself to have the space the same way you’ve just given for your patient.
Is there a role for journaling in there, you know, there, there might be some issues with legality and HIPAA, at least in the United States, just being able to talk to people about what’s happening with your patients, although it’s easy to make these fairly anonymous. You know, if you’re speaking to a spouse, or a colleague about a patient, it’s really important that you leave out any identifying information because the legal issue Yeah, so here’s the thing. So your lawyer before you Yeah, before you Again,
well, it’s not about your patient. In the end, we can say it’s about our patient, but really is it’s about us where there’s something that we experienced with the patient that’s bothering us. So it’s you don’t even have to talk about the patient. It’s about what’s bothering you what’s unresolved in you, that working with a certain patient has brought up, but it’s not about the patient at all. It’s about your experience of that. So it’s working with someone, again, trusted, confidential space where there’s no risk that they will expose that information. And you can, again, de identify everyone involved in the situation, but really is about an opportunity to talk about yourself and learn about yourself. And journaling is definitely part of it. But it requires a structure like, you know, we could do a stream of consciousness where you’re just writing whatever’s on your mind and just offloading it. There definitely can be therapeutic. You can use a self reflection practice that is helping you get clarity about a problem or, you know, again, something that’s weighing on you. By the way, what I find the most powerful is when you’re doing it in the presence of someone else. Someone else is witnessing you. They’re not trying to solve your problem because they can’t, it’s not them. They don’t have more expertise in your problem than you do. It’s your problem. It’s them just being open and holding space and allowing whatever that’s lying underneath to reveal itself. So, so is the
listener, an empathic listener, or a compassionate listener?
I think the both of you need both. You can’t have compassion without empathy. It’s like I say, empathy is the doorway to compassion because you don’t know compassion is the action. You don’t know what to do unless you are able to attune to what’s needed by that person. What’s needed or what’s needed in that situation. And what’s needed is not dictated by you. It’s dictated by the moment you know, like I said, some Breaking Bad news. You think you have to kind of appease them and make them feel better before you know you send them on their way. That’s not necessarily compassionate because you didn’t give them space to actually grieve and maybe they’re not really great at grieving or, you know, expressing emotion You allow that you enable that to happen, which is a really good thing. So compassion is the enabling the allowing the permission, the non compassion is the pushing the for things that are trying to control.
Are there any other self care practices that you recommend? And
I’m all about talking as you can tell some of the talking and
debriefing with again, a trusted person who knows how you how they can support you, you’ve told them or you’ve trained them on how to support you. Big one is reflective practice. So, you know, one form of that or shorts rounds where you know, that’s a way of getting together with other physicians or your team and talking about things that occur in the workplace and, you know, holding space for these conversations to happen, which are often held secret and buried in shame because somehow we’re supposed to believe we know everything, and that we could do everything perfectly and that that’s not possible. So the short surrounds is One format reflective practice is a more structured format that also allows you to figure out what next step to take or how to do something differently. Because you would have reviewed the impact of your actions with a patient with a colleague, whatever the situation is, and then learn from it, and learn and think about how you could take a different step forward next time. And it’s really, again, non judgmental, very open, and about Problem Management. So those are two very powerful ways that can prevent compassion, fatigue, and they all involve talking about everyone’s favorite subject themselves themselves, right? But what we also learn from everyone in the group, what you learn about from someone in the group also applies to you. So one person shares their issue and it becomes a group kind of learning opportunity, because we all experience these things.
Is there anything that we didn’t talk about today that you’d like to mention to our physician audience, either about assertive Or compassion fatigue?
Yeah, cuz. Yeah, I think overall it’s learning I guess overall, it’s learning how to be okay with the myriad of emotions that we get exposed to and the emotions that we feel. And the more we allow ourselves to be uncomfortable, the easier it becomes to be with someone when they’re going through their toughest day, and not trying to make them have any other experience and the one they have, and it’s less and less energetically taxing on us. And it’s actually more supportive for the for the patient. So everyone benefits from that kind of interaction.
I think I heard Tim Ferriss once say, a successful life is judged by the number of uncomfortable conversations you have. I think there’s something to that,
that and that’s assertiveness, exactly. It’s it’s naming the elephant. So in my book, I talk about ways I provide scripts on naming the elephant and it breaks the tension in the room and again, it brings some relief to everyone in there.
So we’re getting People find the book and where can people find you online?
Well, I’m on Twitter a lot. And it’s where I found you. That’s very family. So I’m at NATS for number four docks. And the book can be found on Amazon. And it’s called a little book of assertiveness. And don’t let the name fool you,
Dr. Natalie martynuk. Thanks so much for being on the show today.
Thank you so much, Dr. Brad 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 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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What Can Victorian Literature Teach Us About Coronavirus/ COVID-19?

What can an English professor with expertise in Victorian Literature teach us about the coronavirus? Germ theory became popularized during that era, so this is when people realized that we were the vectors of our own illnesses. One would think that this would cause us to isolate ourselves from one another, like we are doing now, but the literature of the time, which reflects the thinking of the time, shows us that it brought us closer together. A message of hope in these dire times.

Dr. Kari Nixon is an assistant professor of English at Whitworth University. She teaches medical humanities, Victorian literature, and is forever interested in death, disease, risk, and why we fear them. Dr. Nixon’s work has been shared on Huffington Post, March for Science, and more.

Her first book, “Kept from All Contagion:” Germ Theory, Disease, and the Dilemma of Human Contact will be in print Spring 2020.

She got her PhD at Southern Methodist University in Dallas, TX, with a dissertation in Victorian Bioethics, which she turned into the aforementioned book. She teaches both Victorian literature and contemporary medical humanities. She can be found at MKNixon.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.

What can an English professor with expertise in Victorian literature teach us about the Coronavirus? Well, germ theory became popularized during that error. So this is when people realize that we were the vectors of our own illnesses, that one would think that this would cause us to isolate ourselves from one another, like we’re doing now. But the literature at the time, which reflects the thinking at the time shows us that it actually brought us closer together. So a message of hope in these dire times. Dr. Karen Nixon is an assistant professor of English at Whitworth University, and she teaches medical humanities Victorian literature, and is forever interested in death, disease risk, and why we fear them. Dr. Nixon’s work has been shared on the Huffington Post march for science and more. Her first book kept from all contagion, germ theory disease, and the dilemma of human contact will be in print in spring 2020. She got her PhD at Southern Methodist University in Dallas, Texas, with a dissertation in Victorian bioethics, which she turned into the affer mentioned book. She teaches Both Victorian literature and contemporary medical humanities, and can be found at MK Nixon 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.
Professor Carr Nixon, thanks so much for being on the podcast.
Thank you so much for having me. I’ve been really looking forward to it.
So how is it that you wrote a book about epidemics that’s set to come out in April of 2020. And, and it was the topic of your dissertation. So this was done years ago. Mm hmm. And it’s being released in the midst of The worst pandemic The world has seen in 100 years. So where is your time machine? What stocks have you been buying Now that everything’s down? So clearly, I can’t ask you about sports betting since the NBA and the NFL have been canceled. So right, how do you? How does it happen?
Uh, you know, the funny thing is that I think, I mean, I guess there’s not too many of us disease scholars, but I would venture to bet and apparently I’m good at betting, you would say, I would venture to bet that most disease scholars would just simply say that diseases always relevant, unless that seem just any professor who is of course going to say that there are esoteric specialty in research is always relevant, which I think is a sort of professorial thing to say, for me, the idea I mean, of course, it is oddly coincidental that my book is coming out in the middle of this pandemic book For me, the reason I wrote the book and the reason I’m fascinated with what society does in the face of disease is because it’s always just a matter of time. It is an inevitability. And that’s sort of a crux of my book on an individual level. I argue that disease is an inevitability we will all get sick. People say death and taxes, but I say death, taxes and disease are the three things you can depend on in life. And so if you think about any other catastrophe, I don’t know, war, maybe I can visualize a way in which we could theoretically avoid war, because we’re talking about diplomacy and people may be negotiating. We don’t get to negotiate with diseases. There’s diseases and disease outbreaks, which are essentially one form of, I guess, a natural disaster. So for me, it’s not that surprising that it happens to come out in this really Relevant time because Have you seen that meme? It goes around a lot of Kermit sipping tea?
What is he saying? Well, he’s sipping tea and what kind of tea is it?
I think it’s Lipton tea tea, okay, he’s always it’s usually captioned with, but that’s none of my business. But he has this kind of look on his face, like he could have told you this was gonna happen. And I just keep visualizing myself that way. Like, the coincidence doesn’t seem coincidental to me, because I feel like the very nature of my book has been kind of screaming into a void, that disease is coming for all of us. And we ought to think about that, when we’re not in that moment of crisis, to understand what we will feel like in the moment of crisis and do better at that point. So,
yeah, so if you can use that time machine again, right, your your book is arranged by disease, each disease, you cover, get to chapter right. So So, you’ve now written a Coronavirus chapter. What are some of the highlights? Or are there no, is there no Coronavirus chapter since people are now mostly buying into germ theory? I’m sure there are some fringe people out there. But really, it’s not. I guess it’s not germ theory anymore. So is that even a chapter?
Right? It’s not really a theory anymore, is it? It’s just germs. You know, I actually think there’s a really great parallel between the things I cover in my book, the diseases I cover, and the emerging Corona virus disease right now. The reason I cover the specific diseases I do and the time period I do is because in the 1880s to the 1818 9597, this 15 year period is this really interesting slice of history in which most people are buying into germ theory at that time, although they are still calling it germ theory. Most people pretty much believe it. They’ve started using Robert Cook’s theories to identify certain bacteria under a microscope. And I’m sure anybody who’s done laboratory science in undergrad or post grad is familiar with Cook’s postulates of how we culture a bacteria in a petri dish and then correlated with the causal pathogen that we see creating clinical manifestations in a patient. So people were believing in bacteria at this time as disease causing vectors. But they had they couldn’t do anything about it. Anything. We don’t even have penicillin till 1928. So there’s this really interesting time period and this little 15 year segment that I studied, in which there’s sort of just this existential horror, and I know that sounds sort of like an unscientific term, but I just love when the sort of cerebral realm of science and history meets up with what are the undeniable Least human components of our existence such as fear and hope and a desire to live. So there’s this existential horror that I noticed in this time period where they suddenly see and identify everything that’s killing them. And they have zero tools against it, except maybe they had started to understand antiseptics. At that time, they had a few they did understand that hand washing and sanitation helped. And isn’t that exactly where we find ourselves today at 6:15pm Pacific central time on March 16 2020. When we have a disease that is an emerging infectious disease, an ID that we don’t fully understand, we are back in the Victorians footsteps where we see something and we definitely see the epidemiological data that proves that it is killing people and all we really know to do is our basic sanitation practices. Just it’s so for me it is exactly that human and societal reaction that I wanted to isolate culture, if you will to use cooks words and Petris words, in this book that I’m seeing, again here with this infection, it’s like you’ve got all the same ingredients, the same media in that petri dish. I’m going to stick with that metaphor until it gets rolled. And and what I’m seeing are the same social reactions on all ends of the spectrum that I identified in my book happening to the Victorians. What do you mean, what are some examples? Well, the thing that I talked about in my book, and sort of the crux of it is that germ theory as it really took hold, and as people sort of looked up, I sort of imagine a married couple looking at each other over their morning coffee with the slow, cold realization that that’s the person that probably gave you tuberculosis. I always see it very cinematically, in my mind. My thesis is that That moment in history, catalyze this sort of individualistic, neoliberal idea that we should just isolate ourselves and protect ourselves. That’s the only way to survive these things that we don’t know how to control called germs. And yet, what I identify in my chapters and as you note, I do it disease by disease because I highlight the different specific social questions coming out of each disease. I identify these really beautiful moments in history where people are saying, No, I will look out for the greater good. I’m not just going to try to hermetically seal myself away in my house to preserve what I call bare biological life, a beating heart, but I’m going to help my community members engage in rich, fulfilling intrapreneurs relationships that are what make life worth living.
Okay, but if you’re listening to this, and the Coronavirus epidemic is still hot pandemic is still happening. Don’t do that. Right. Your house?
Well, no, no.
Listen right now this comes later.
Right now double down. I’m gonna double down. It’s what I do. Here we go. So yes, we are isolating and staying in our home and social distancing, which I would actually love to talk a bit more about this because my first chapter goes way before the Victorian era and talks about Daniel Defoe writing about plague in 1722. Way before germ theory and he my whole chapter is about how he promotes social distancing. Before I became apprised of that term with Coronavirus, but no, I mean, of course, I don’t mean ignore public health mandates and that would never be the goal of medical humanities. The first thing I would say is of course, my book is a literary criticism books. I am able to identify the ways that authors promote the communal good in the imaginative space of literature, right, where people are actually dying from this. But secondly, I actually think that we have much greater opportunities to live this out real in reality than the Victorians did because we have social media. I mean, I’m sitting here right now having a really fulfilling, Enriching conversation with you, in spite of the fact that we can’t leave our house
and then never would have taken place had we not gotten in touch over social media. Exactly the toxicity that occurs in there.
Yeah. And I mean, I haven’t seen so many people saying, you know, people with people that are extreme extroverts people with really high anxiety right now people with substance abuse disorders that can’t get to their a meetings right now. Reach out to me, I’m seeing that on Twitter. I’m seeing people develop groups Hangouts and FaceTime and acknowledging what I, again, sort of as an academic feel like I just kind of scream into the void of my office so often, that these social relationships are why we’re trying to keep staying alive. It’s not just the functional existence of a beating heart. It’s because we like other people, and others,
right? Yes, yes. And you’ve seen the great videos coming out of Italy, I’m sure that have gone viral. Haha, pun intended, intended of the Italians singing together from their balconies, and enjoying the communal space of song across a busy street and a balcony. So they’re safe, but they’re together. I mean, I just, I actually think we absolutely are doing these things because we’re lucky enough to have this technology. Now.
Another thing that I’m seeing is crowdsourcing of information I’m a member of a bunch of physician communities, and just the exchange of ideas globally, and I’m just floored by how smart people are like, like, you know, yet we don’t have a vaccine for this. We don’t have a medical treatment for this. But what worked into your IC? What’s been working for you? Have you tried this? Have you tried, we tried this, like, just, you know, clearly not disclosing patient information, but like, just the back and forth and the exchange of ideas is, you know, across the globe, it’s a testament, you know, how social media just shows the rawness of how horrible we can be to each other, and how creative and wonderful we can be.
Yes, I always say it’s becoming more and more of my mantra, as I think these things become, I think, as you say, more more raw and exposed in times of crisis, which again, is why I think diseases is interesting space to study. I’ve been seeing more and more humans are my Least favorite and most favorite part of humanity? Um, yeah, I’ve been seeing it in my profit sorial communities, because so many of us are now having to suddenly teach online. And just the way people have come together to make sure that we all are focused on the most ethical way to handle this with our students. I mean, initially, I was thinking, we’re talking on a zoom meeting right now You and I, I was like, Well, great. Like, we’ll just zoom all our classes, it’ll be fine. And I start seeing people posting and making Google Docs that are open access, saying, you really can’t assume that your students have internet reliably at home, if they can’t live in the dorms anymore. For many of them being on a college campus was a vital point of access to resources. Please don’t do synchronous learning. You’ve got to do asynchronous learning where they can get on when they can. And I’ve just been so grateful that as much as I try to do my best as well that we can crowdsource these things and Think about things that we may not have thought of. Or, for instance, I was home insecure as an undergrad, I didn’t have reliable housing outside of my dorms. So my students that might have been displaced into an unsafe non existence or unhealthy home when the doors closed, it was at the forefront of my mind. And I emailed all the professors in my department and I said, What do we do like we could probably offer students a place to stay. But I don’t want to offer students that are currently taking my courses a place to stay because that gets kind of thorny when I’m still in greeting authority. And we sort of develop this elaborate system by which we would house one another students to make sure that nobody was housing a student they were grading but that all the students have housing turned out to be unnecessary because my university opted to keep limited dorms open because they weren’t thinking about students, housing security, but like you I’ve seen my communities coming together and I also say, you know, academics can, they can sometimes not be the most pleasant people. But I’ve seen like the best and my most, my favorite sides of academia and why I became an academic coming out of this crisis, one of
the questions that I had was gonna lead to, can you please restore my faith in humanity with all of the horribleness that’s about to ensue? And you did. So we will not be able to skip that question. Thank you for restoring my faith in humanity. So, during our first season of my first season of doing this podcast, I had an episode called bad words. The title was longer than that. But the idea is words. While we think that our ideas help us choose our words, and they do, words can shape our ideas so that the interview was in the terms of patients with weight issues. But you say that our words can shape our ideas with regards to Even a pandemic, so and can ultimately influence the pandemic. So given that this is a largely physician audience, how can we as physicians utilize language that we use with our patients to convey the appropriate amount of gravity, right and help to help to shape that outbreak narrative that you talked about? Right?
Well, I think what you’re referring to is something that I started calling it this in my teaching, just kind of, because it’s what made sense to me and my students have found it really helpful. So I’ve, I’ve kind of developed it further, I believe it was in my cnn article, and it’s a huge part of my my second book, I call what you’re discussing this dynamic, this socio scientific discursive cycle, meaning that of course, as you say, the way we talk about things can affect the way we frame scientific questions and inquiry. One really concrete way to think about that as it may frame the grant money that people ask For and what they’re asking to study with certain grant monies, but that also, of course, the way we develop that science then filters into the way we speak, generally. So the fact that we just mentioned something a meme going viral Porsche that comes out of the original notion of biology developed in the 1940s or so. Yeah. So, initially, what I was focusing on with this pin, well, before it was a pandemic, or recognized as one was really talking about Origin Points of viruses, that has been something kind of a soapbox of mine, I suppose you would say that when, when we try to identify a patient zero. And this is where you’ll have to let me know if you if if I’ve lost you, because people sometimes bristle at this idea. I’m not saying that epidemiology is incorrect when they identify a patient zero, but what a medical humanism General would ask is when we frame the question that way to pinpoint a single source of an infection. What are we implying by that? And what are we looking for? And what might we be not thinking about? When we ask that question? The answer to that I would suggest is, I mean, we essentially are wanting someone to blame. I would think right now, there may be broader scientific reasons why we just need to know an origin point and I cannot speak to those nor do I intend to. But I do think it’s very, very stunningly human that we would like to figure out what started at all, and I think, therefore, that easily slides all too easily into blame. One of my favorite scholars ever from whom I learned everything I know about patient zero and healthy carriers and outbreak narratives. That’s her term. Her name is Priscilla Wald. She’s at Duke and one thing I love about her book. In her intro, it’s called contagious cultures, carriers and the outbreak narrative. she identifies the way that over and over and over again in history, we tend to say that diseases come from the east. We being Of course, Western culture. And what’s great about the way she does this intro is she does not at all address, whether she’s saying the epidemiology is accurate or inaccurate. It’s not a point of her argument. That’s not her field. She’s a literature scholar like me. She simply presents it as the narrative that we’ve said about h one n one and SARS and MERS. And she just lets the that speak for itself, so that you can leave her book in my opinion as a reader without thinking that’s just a little too convenient for us over in America and it makes you want to know more About if there might be some myopia in the way we’ve constructed these epidemiological questions that perhaps keep leading us to the same answer at the exclusion of other possible answers. I hope that didn’t sound too much. Like I’m trying to debunk the entire field of epidemiology. I’ve, as I was editing my cnn piece over and over, I kept getting that criticism, and it’s certainly not my or any medical humanists. I know. It’s not our intention,
know that the pattern is definitely there. Is it coincidence? Or is there actually something there? I’m certainly under qualified or completely unqualified to answer a question like that. But But I would think identifying a patient zero identifying where this came from, you know, we need things like that in order to find order in the chaos. Right? And just that’s, that’s a very human it’s a scientific need. Right? Where did it come from can help us hopefully prevent another one but it can also inform us as to What might help in terms of treatment? Now? I’m just I’m just guessing there, do we need to know patient zero in order to in order to accurately track the spread? Clearly, that didn’t help us here? Because it was being community spread before we realized it. So, yeah, I don’t know. Those are definitely interesting concepts that bear some evaluation, right. always seem to come from the quote, other.
Right, I think and something you said and the way you said that back to me, maybe it kind of clarified for me a better way to say it, but what we would say in the medical humanities is not that it’s necessarily wrong or not wrong, but that if we as a society aren’t seeing that there might be a potential bias there. If we’re incapable of possibly identifying possible biases, then you’re just absolutely certain to get some biases, right. So we’re always just trying to get people to like, think in different frameworks all the time to make sure that we do better science to make sure that we’re not missing something.
Yeah, we’re always bringing in our biases, we need to recognize that in order to account for it in order to make sure we’re being as objective as possible.
Exactly, exactly. I think I might have answered your question in a really circuitous way, the xenophobia was on my mind. First of all, as the disease has developed, what I’ve been more concerned with is ablest language, people saying, you know, well, it’s only gonna affect the infirm and the elderly. And there were great disability scholars coming out on on Twitter and Social Media and saying, you know, that’s unacceptable to phrase that as though the rest of you know people without those conditions can stop worrying because that treats that population as disposable. I I feel like the medical community has done really great with this. I would not suspect generally that doctors would have been perpetuating any of those problematic stereotypes. But I do think that risk is really hard to convey accurately to patients who are almost certainly not medically as medically literate as their doctor, right, by definition. Well, and
that also has been a problem in our past, as you mentioned in the that same cnn article, right. So syphilis was seen as a disease of sex workers, not a disease of the husbands that were then taking it home, their wives who were then giving it to their children, you know, their their unborn children, or HIV being a disease of homosexuals. So thinking that it was only affecting homosexuals while it was rapidly spreading in the heterosexual community as well. So by thinking it was a disease of the other, right, that helped it to continue spreading, and that’s happening right now with the Coronavirus, right like I’m sure we all have seen pictures of millennials out at bars, carousing and spreading them. Guess that shows that I’m not a millennial prior to them as carousing, and potentially spreading the virus among themselves, and then spreading it to others beyond that, right, so they’re disregarding it because it’s a disease that primarily affects the older population and those with comorbidities.
Right, exactly. I mean, we’ve talked about seeing the the most beautiful parts of human nature, and that would be the part that has disturbed me the most is that again, that I identify in my book, that sort of individualism of well, if I’m gonna be okay, then who cares about anything else. And the American concept
it is It is I, the older I get, maybe I’m showing my age here, but the older I get, the more I’m convinced that that’s the root of all our problems in America. But I think
also the root of our solutions, like, I can figure this out. Whereas in America, you feel more empowered to be able to innovate. Whereas other countries, if you’re the member of a cast, I mean, we do really poor this poorly with this in terms of socio economic status and race, right? Where you might not feel as empowered as you otherwise would be if you were a white male, who feel like caught as a white male, you know, you feel a constant sense of empowerment. But but in America, like you do have more social and mobility than in other places, and more of an opportunity to innovate. And that’s why we see all these, you know, innovation happening, certainly happening other places in the world. But, you know, America is definitely a popular place where that for that to take place. So the individualism is horrible, when you’re being horrible to each other and ignoring other people’s needs. But at the same time, you know, I have an idea. I think I can do this in vain,
that American gumption
like that, yeah, yeah. And do attitude.
No, but you’re absolutely right. I mean, I think that’s the sort of problematic attitude that, in fact, is allowing it. I mean, we see it epidemiologically It’s a fact that that is how it spread, because people weren’t worrying early enough about the most vulnerable among them.
Yeah, unknowingly putting themselves at risk because, right some of the data that we’ve seen said there’s the mortality from this is point 2%. in I think it was like 10 to 40 year olds and and point 4% in 40 to 50 year olds. So right point 2% seems like it’s not going to happen to you, but if you’re if you’re in a high school of man, am I going to do this math correctly? Let’s say 500 people, right, your high school class then that means that I’m gonna get this wrong, you know, one or two people are gonna dive It doesn’t mean the middle but you know, that’s what this is. So, so like, right, well, that you know, like, and yet you’re out and passing into among each other thinking that you are invincible, right.
And one of my students told me about Coronavirus parties Where people earlier on were using it for the masks and stuff for costumes. And again, that speaks to this sort of privileged flipping, see that it’s not going to happen to you. And yeah, I think one of the ironies I tried to highlight in my cnn piece is that you get really rude awakenings when you behave that way. One of the texts that I discussed in my chapter on syphilis, actually is by Henrik Ibsen. It’s a play called ghosts. And it is literally about the the way that his mother tried the main character his mother tried to hide from the main character, the fact that he had syphilis. She tried to stay with this philandering husband to have this perfect seeming home, that that in fact delayed him getting this imaginary treatment in the realm of the play and causes his death doodoo syphilis and He was writing that in direct response to exactly what you said, these sort of, quote unquote good Victorian middle class women who are giving birth to babies with the sniffles. You kind of only learn about this in medical school anymore because you don’t typically see congenital syphilis these days, but the sniffles and the notched teeth and all these very physical signs that a mother could see the second she held her baby just as easily as a doctor could that this was not what she had imagined. And it was striking visual evidence of the epidemiological fact that these were, as Epson called it. The ghosts of their behaviors and prejudices coming back to haunt them.
And it’s happening now. Well, history repeats itself, so that’s why we need It’s why we need more historians out there. I’m sure you’ve been shouting from the rooftops for a while from the very beginning here.
Yeah. Well, I mentioned the Kermit tea thing. That’s kind of how I keep thinking, you know, a zombie class this January. And we use that to talk about access to health care ableism cognitive alterity so many different things. And one of the movies of course we watched was contagion even though that’s not a zombie movie zombies have become sort of synonymous with contagious disease these days. And it’s been funny to watch people online now watching contagion because now it seems relevant to them. And, and as I said in the beginning of this interview, for me, it’s always it’s always been relevant. It’s always been about to happen to us. And now just finally have
your classes next semester are going to suddenly get a whole lot more popular.
I know my poor kids in my zombie class thought it was all theoretical. And
then I Oh, and the CDC years ago played on the popularity of the zombie theme by having a page for what to do during the zombie apocalypse, but it was just a way for them to publicize disaster preparedness. For any disaster, there are a few things you’re going to need. And they just, that was just the same list they had for every disaster.
And then the required text in that class a stroke of genius. Yeah, they have to read that and analyze it and kind of tell me what they think it means about our society.
So, do you have any any parting words for the physician audience in the age of Coronavirus? What we should be looking for what should be prepared, how we should be talking about it, how we should be addressing it to to patients or we happen to have the media in front of us?
Ah, well, I mean, I think I would just circle back to sort of the theme of this whole interview that times like this give us the ability to really live our values, whatever those may be. And that applies to doctors of course to right now. I feel like doctors just by you know, being on the front lines of this even in private you know, non hospitalist practice are doing that but I think just kind of realizing teach my medical ethics students all the time, my my sort of mantra, I hope I don’t get in trouble for this. My mantra to these, these pre med kids is Kaiser Permanente is coming for you. You think that you want to help people, that’s why you want to be a doctor and because you’re smart, and nobody’s going to warn you until they throw you into the trenches that you’re going to have a 15 minute appointment slot per patient. seven of those minutes need to be writing up orders and notes. So you get eight minutes for a patient who is a human with a history and needs and worries that are uniquely theirs. And I mostly spend my entire medical ethics class teaching my students about the lack of ethics in the pressures that are put on doctors today, and just trying to give get their heads wrapped around that so they can prepare now for how to make maintain their humanity and the good heart that got them into doctoring. When those pressures arrive, and I guess I would just say that this is a great time to try to, if you can like be in the moment and just be the human talking to another human. That is the reason you got into medicine because at the end of the day, nobody really knows perfectly what to do. And so I think more than anything, what we’ll call them patients down is that human connection that so many people crave from their doctors, and I say all that background to say that I completely recognize the pressures that are on doctors to do that to stop for a minute and say, Okay, I’m a person, I’m talking to a worried person. Let’s start from there. But I think you know, in modern society, we all unfortunately are under those very frustrating economic Productivity pressures. And it behooves all of us even myself as well to stop sometimes and just remind myself why I’m doing this to begin with and as doctors, and for me, too, as a disease scholar, this is that moment where I think we are called to do that as part of our calling.
I don’t think we can hear that enough. No, we do. We do hear that. But certainly, we could hear it more. So I appreciate that. Professor Carr Nixon author of kept from all contagion, germ theory, disease and the dilemma of human contact. When is that available? And where can we find it
should be coming out in June? I have not been willing to ask it if it’s delayed because of the COVID issues, and it’s coming out from SUNY press. You can follow them on Twitter, and they’ll definitely be there promoting the book a lot lately because of
its relevance to the press. I’m a Sunni graduate, myself and your alumni in Washington.
Yeah,
that’s awesome. So you press All right. Well, Professor Carr Nixon. Thank you again. And hopefully we will get to do this again. Thank you 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 web page. Also, please be sure to leave a five star review on your preferred podcast platform. We’ll see you next time on the physicians guide to doctoring.
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Trauma Response for Good Samaritan Physicians with Stephanie Streit, MD

Stephanie Streit is a trauma surgeon at University Medical Center in Las Vegas. She went to med school at the University of Cincinnati and did a general surgery residency at MUSC. She is currently active duty in the Air Force. She is also the host of the Breaking Scrub Podcast, where she interviews surgeons about the interesting things we do outside of the operating room. She is convinced that success outside of the OR breeds success in the OR. Did you hear that, med student? Stop tying knots and pick up your clarinet!

We start out talking about some of the more routine and mundane parts of being a trauma surgeon. We then discuss something I didn’t quite expect: how important it is to her to address the mental trauma, not just the physical trauma, in her patients. We then discuss the beginning of a trauma assessment, which is CAB, not ABC and how stopping a life-threatening hemorrhage is likely the only thing you can do if you find yourself at the scene of a trauma. Hold pressure and stop the bleeding! We close with discussing why we podcast and her biggest takeaway from her show.

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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.

Stephanie straight is a trauma surgeon at the University Medical Center in Las Vegas. She went to med school at the University of Cincinnati and did a general surgery residency at USC. She is currently active duty in the Air Force. She’s also the host of the breaking scrub podcast where she interviews surgeons about the interesting things that we do outside of the operating room. She’s convinced that success outside of the or breeds success in the or did you hear that med students stop tying knots and pick up your clarinet, we start talking about some of the more routine and mundane parts of being a trauma surgeon. We then discuss something I didn’t quite expect, how important it is to her to address the mental trauma, not just the physical trauma and her patients. We then discuss the beginning of a trauma assessment, which is c a b, apparently not ABC. And how stopping a life threatening hemorrhage is likely the only thing that you can do if you’re finding yourself at the scene of a trauma. So hold pressure and stop that bleeding. We close with discussing Why we podcast and her biggest takeaway from her show?
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 is that they are quickbook professionals with over 20 years experience focusing specific Typically on health care, 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.com. That’s OCB m Ed, or call at 833-671-3873 or 949215 6200. And check out the show notes for more information. Dr. Stephanie stripe. Thanks so much for being on the podcast.
Yeah, thanks for having me.
So if you had a medical student who was considering going into trauma surgery,
what is it that you’d want them to know before choosing the field that isn’t readily apparent during the rotation? So you got you got your third year student, they love the rotation. They’re like, Oh, torture, shredding. Definitely. I definitely To be a trauma surgeon like you, and you had to sit down with them, what were some of the things would be some of the things that you would tell them that maybe they weren’t, wouldn’t be privy to?
Yeah, you know, this is happening more and more and it for some reason, It surprises me still that I get these young people who and even I’ve mentored high school students who want to be trauma surgeons, and I didn’t even know what a trauma surgeon was when I was in high school and college.
Yeah, er isn’t on TV anymore,
is exposure. And even most of them it was only Eric was out. It was a surgeon and all the other ones were doctors. I didn’t get that when I was in junior high either. But no. So, you know, a lot of young people will get excited by the pace or the adrenaline or they’ll have you know, one really intense interaction. Maybe somebody comes in really sick after a car crash or they’ve gotten shot and they students experiences really intense interactions, and wow, I really want that But maybe what they don’t see is the what we’re doing when that’s not happening. A lot of trauma care is not exciting. It’s following up on CT scans and doing wound care. And, you know, a lot of times it’s telling people that they’re going to be fine, because they’re not injured. And you have to be happy with those things, too. You have to be sustained by the boring stuff. And you can’t just rely on the adrenaline rush, because it’s really actually depending on where you work, it may be really few and far between how does
the well then they can fill their time by getting active on the blogosphere, they can share they could get involved in real estate investing or something like that. Like we’re, you know, we’re seeing a lot of that out there. Well, first you said, you know, you see some patients that are fine, how I would think that those wouldn’t end up in front of you like what are the patients our the patients that are fine, ending up being evaluated on it? trauma surgeon if they’re fine?
Well, you know, it really depends on what kind of center you work in and what kind of trauma system you’re in, that most trauma centers are dictated by some variation of the CDC guidelines on what’s called pre hospital trauma field triage criteria. So those are CDC recommendations for who should be taken to a trauma center that doesn’t necessarily say who should be a trauma activation, meaning the trauma surgeon is there when they get there. But every center and every system is a little bit different on how it actually brings the trauma surgeon to the ER how and when or for whom I should say the trauma surgeon is brought into the emergency department for when the patient arrives, there’s a degree of what’s called over triage in every system, which means that it’s basically Better safe than sorry, that you would rather over call your trauma surgeon than under call your trauma surgeon. So there’s always a person percentage of people who end up you know getting a full evaluation and going home at the end of the day because even though things look bad on the scene, you know, by mechanism, maybe it was the car was dented by more than 18 inches in the passenger compartment for example, which is a can be a marker for somebody being injured, but in modern day vehicles, that’s often just a reflection of how the materials are meant to crumble and is not actually and people are actually quite safe. So those those triage mechanisms are meant to be better safe than sorry, got it.
You were kind of getting into that. And this is something we spoke about on your show, which was finding joy in the routine. So you said you know the routine stuff for minefield it would be like ear wax and that’s what we discussed. Like I just didn’t I enjoy it. much I enjoy removing it but like I have, you know, these recurring patients where it’s like low stress situation, how you doing, talking about your family, I’m kind of like a barber it’s, you know, if I find out join it. So, first, you mentioned a couple. But could you elaborate more on on some of the more routine things and then go into some of those routine things that you manage to find the joy in that on the outside look kind of boring?
Sure. So you know, blunt trauma is most of what we do. So that’s people who get into car crashes or motorcycle crashes or they fall. And they often have relatively low energy injuries. And the ones that bring them into the hospital most often would be things like having broken ribs, and there’s a lot of anxiety associated with broken ribs because it’s your breathing. And if you if it hurts, every time you breathe, a lot of people will become very anxious about that. And they can get into this kind of mental spiral. And, you know, and then they’re coughing and then they’re not using good respiratory mechanisms, and then they’re actually ending up in a more morbid Not that’s not the right word. But they they can end up in a being a little sicker than they necessarily were to begin with because they become so anxious and so fixated almost on their breathing and on their on the injury. So part of what I tried to find comfort in or not comfort but I find joy in is coaching people on the experience of discomfort, fulfillment, I think you find your mean you find fulfillment in this Yeah, that’s that’s a better word for it. I when I can coach people through the discomfort and have them be more be you know, just breathe easier, literally, and figuratively breathe easier on the other end of it. That’s a really common thing that I didn’t think that I would find fulfillment in but I do
wonder the difference between your field Mine is, you know, I’ve ongoing relationships with a lot of my patients. And, and you don’t. And so when you choosing the field, I would think that that’s something that you kind of actively decide is less of a priority, right? Like is is the doctor patient relationship yet somehow you’ve managed to make that an important part of your, your practice. Like that’s something that’s that’s become important to you that you find fulfillment is that is that interaction?
Oh for sure. It’s definitely different than what you have where I don’t see people over and over again. Well, hopefully I don’t see people over and over again. And so maybe don’t necessarily get to know their families or follow their kids sports, like you might get to but the intensity of the situation definitely creates an opportunity for a really meaningful patient interaction, just the same
real human connection. Mm hmm.
And it can be really hard, you know, a lot of patients, probably one of the things that I hear You know, really, really often that is frustrating to me. And almost hurtful is how often patients say, well, you don’t understand. And it’s no matter how hard I try, no matter how long I sit and try and listen, the intensity of the situation really is isolating to patients in a way that’s very unique and very personal. And so I can’t possibly understand I don’t know what their what it is that they’re losing out by being in a hospital bed. I don’t know, their financial situation or their family situation that’s being harmed by them being in a hospital bed and not being at work or being in school or whatever it is. But it’s, I still find that very motivating, to try to try to understand,
well, you’re you’re highly trained for the physical trauma, but you’re also managing to treat the simultaneous mental trauma
you know, I try but that’s something Our whole system just really doesn’t do a good job of, we’re just now starting to recognize the long term psychological consequences of physical trauma. More somewhere between Some studies have said, you know, 20, and up to 60% of patients will have symptoms of either depression or PTSD or both at six months after a significant trauma. And our system just is not good not capable of absorbing that right now. But the first step is is acknowledging that it’s happening. And and that starts with the immediate post trauma care while they’re still in the hospital.
Yeah, it seems like a great opportunity to even you know, once they’ve had time to process the whole situation to inform them that this is a possible outcome that they need to be aware, so that rather than you know that they they see it happening to them.
And I, you know, that’s a conversation that I have in clinic and follow up a lot. And sometimes even just acknowledging it is a huge relief to patients when even just saying it out loud and saying it’s okay. And this is normal. Sometimes that’s enough to take a little bit of the burden off in the short term while they can while they’re still recovering. But we definitely saw a lot of work to do as a as a system.
Oh, I’m sure I’m sure they think they’re going through going mad. You know, they’re they’re falling apart at the seams and, and this is they don’t know where it’s coming from. And yeah,
yeah, they feel weak. They feel like they did something wrong and they feel like, you know, other people don’t feel this way. It’s incredibly isolating, especially when you end up you know, relatively homebound or missing your work or your school or whatever your routine is. And they definitely get into a spiral and sometimes just Now alleging the spiral is enough to at least slow it down, if not break it.
This conversation with a trauma surgeon is definitely not going in the direction that I thought it was. But But still, it’s, you know, extremely interesting, extremely informative. So but let’s get let’s get back on the path of the of the physical trauma. So, let’s say you get called to evaluate a patient and you’re the second physician to see this patient. So, you know, it’s still still I’m not so clear on the pathway of who gets seen by the ER doctor and who gets seen by a trauma surgeon. But let’s say for whatever situation, either the ER doctor and internist, maybe in a resident that’s rotating on your service, either way, you are the second physician to see this patient. What do you hope has already been done and I know I haven’t given you any information about what the trauma was. But that’s kind of what I’m looking for is like, you know, ABCs the ABCs of trauma
What I was going to say, I hope somebody already did the ABCs Yeah, depends on depends on the situation because if somebody has already seen them before me, then the chances are they’re not as sick. But yeah, I hope somebody has done the ABCs and somebody got an IV and Okay,
come on, you’re stuck in the elevator just like help me out with this scenario here. Right? You’re you’re running down seven flights of stairs because the elevators broken and there’s already another doctor there. What are you hoping this doctor has already done by airway, breathing circulation, so that
breathing circulation so in in trauma, you know, a lot of people will put it as Civ especially for penetrating trauma. You know, so if there’s uncontrolled bleeding, I hope somebody put some pressure on it or put a tourniquet on it. If it’s an extremity
and don’t do that nosebleed please.
My neck, you know,
we cut off the circuit Quarter
stopped, we stopped,
can’t get the start at two been in the immediate care for trauma, you’re looking at the things that can kill you right away. So those are your tension pneumothorax, your cardiac champ, an odd traumatic brain injury related respiratory failure, and then uncontrolled hemorrhage. Those are your immediate life threatening things that I that are always on the top of my list whenever someone comes in to make sure that they’re not present. So I hope that somebody is doing that for me.
And then and then what happens from there. So so you’re going to control a hemorrhage, you’re going to make sure that there’s not some immediate like life threatening injury, like tension pneumothorax, cardiac term temper nod or they’re going to herniate their brainstem potentially and stop breathing. And then and then what happens from there with regards to the assessment,
so depends on in general, we’re following what’s the American College of Surgeons advanced trauma, life support and so on. After you do your primary survey where you’re looking at airway, breathing, circulation, disability and exposure, then you’re looking, you’re using things like chest x rays and fast exams, which is an ultrasound to the abdomen and the heart and the lungs. And, again, looking for those immediately life threatening things. And if those aren’t present, then you moving on to your secondary survey, and you’re creating a plan to finish your assessment. So in most cases, if people don’t have an immediate life threatening thing, they don’t need to go to the operating room right away. Most patients are going to end up in the cat scanner.
So we’re going to change the scenario a little bit. So one thing that I like to cover on this podcast is, is how to be a good referring doctor. So if I’m interviewing a specialist, what is it that you want your referring doctors to know so that they can do something before they refer to you or stop referring you this type of patient or something like that, but I would imagine you don’t really have referring doctors right now. You know, that they’re just that’s not helpful. end up in your travel bag. So on the other hand, right. The other thing that I like to cover is what every doctor should know about your specialty because we’re all doctors, right? And so there’s a certain expectation of what we’re going to know. And so, you know, I had spoken to an ER physician about a cardiac arrest. How do we handle that? If we’re a pathologist, who knows what cardiac tissue looks like, under a microscope, but right, they don’t know how to deal with cardiac arrest. so in this situation, we’re gonna make it more of a trauma situation. I’m out for a walk with my family, right. And I see a car Korean into a tree. So I run up to see how the drivers doing. And everybody’s looking at me and expecting me to know exactly what to do. If you could walk us through a trauma assessment where you don’t have access to your cat scanner where you don’t have access to maybe a syringe to to emergently drain cardiac temping odd if I if that’s actually you know how you do it or put it another way Let’s say I’m in Iraq. I like to choose other specialties, right? So put another way, I’m a neurologist that happens to be a bystander at the trauma. But I’ve left my reflex hammer and tuning fork at home.
But everybody’s looking at me to do something because I’m a doctor. Sure.
So I would say, first of all, your pre hospital providers are your best friends. So first thing is just call 911. You can’t you really can’t do a whole lot without your tuning fork. So if the things you can do on scene after trauma would be to assess for life threatening bleeding elbow, I’m sure a lot of people have heard of stop the bleed, which is a campaign that was started by the American College of Surgeons along with the joint trauma system and the pre hospital organizations to teach bystanders how to be lifesavers when it comes to life threatening bleeding. So I think any physician should be able to look for and assess for life threatening bleeding and then try to stop it. I carry attorney Get with me almost all the time, but I don’t expect everybody else to. So just doing things like holding pressure to an area that’s bleeding to try to slow it down until pre hospital providers get there. Did you use something like a belt? You know, we don’t really recommend that people try to improvise tourniquets mostly because while you’re trying to improvise the tourniquet, there’s still bleeding. And the majority of bleeds can be stopped with direct pressure or with packing a wound with something like a you know, clean t shirt. Most bleeding is going to be venous so you can overcome the pressure in the venous system, just with direct pressure most of the time.
Sorry, while we’re on the topic of tourniquet, I think it just bears mentioning for my specialty that you can’t turn a kit a nosebleed so a lot of people when they’re trying to stop a nosebleed will put the pressure over the nasal bones. Mm hmm. Thinking that that’s where the blood supply comes from. Mm hmm. That is not where the blood supply comes from. The blood supply comes from underneath the septum. It comes from behind the septum. It does not come from the the skin or the nasal bones, you’re not creating a tourniquet effect by doing that, you’re just waiting for the blood to clot. So if you are going to stop a nosebleed, you pinch the nostrils shut. That’s it because the vast majority nosebleeds are from the anterior septum. And you put pressure on the ampere septum by pinching the nostril shut. So sorry, I thought you mentioned the tourniquet and applying pressure, so I just wanted to put that little PSA in there. Okay. Sorry. Okay. So, so, so don’t go looking to improvise a tourniquet your bandana? Whatever, just put pressure on it.
How much
Okay, so that but you said it’s not ABCs? Right? It’s si si a be
a lot of time, man. It’s me. Okay, because, you know, in the majority of preventable deaths from trauma is from hemorrhage. So if you can find external hemorrhage or an external source of hemorrhage and slow it down or stop it. That’s the most The way that you can be most impactful, got it.
Okay. And then you can even task somebody with doing that, once you’ve identified it, put them on it, and then you can go over to the airway.
Yeah. And you know, because there’s not a whole lot you can do without your trusty oxygen tank, they you carry around. So there’s not a whole lot in the pre hospital setting that a doctor can do, apart from try to do like a jaw thrust, because in general, we don’t, you know, and when people are in a significant trauma to the point that they have an airway problem, we also worry about their spine. Yeah, so you don’t want to move them around a whole lot. Or for example, put them in a position of comfort or recovery position, which is typically kind of on their side towards almost towards a fetal position.
Although you don’t want them to swallow their tongue turn them on their side. Yeah, not not a good idea.
Right. So that’s where the pretty much the only thing you can do pre hospital before your MS folks arrive is to do something like a job for us to keep their their fair is open if their mental status is altered, otherwise, you know, the majority of people will breathe, it will be breathing just fine on their own.
They’re awake, just stop their bleeding. So that remain awake. Yep. Okay, and then just wait for 911 I think that’s, that’s something that separates physicians from from lay people in situations like this is we kind of understand when we’re at the limits of what can be done, like, you know, someone else might be running around. I don’t know, what else can we do? What else can we do? What else can we do? The doctor you know, we know this is it. This is what we can do. We just have to wait. And then you know, wait for em is too common?
Yeah, I’ve you know, I’ve stopped it car crashes and motorcycle crashes and even as a trauma surgeon, apart from I literally will come to the scene with my tourniquet in my pocket and assess for life threatening bleeding and somebody’s bleeding. No. bleeding. Are you bleeding to death? No. We’ll wait. We’ll wait for the ambulance. See at the hospital.
Yeah, just picking up the shift right now. So let me reach it. I’ll be better if I just get back in my car. Exactly. Right. He there.
Exactly right.
Okay, so is there anything else about trauma surgery? Knowing that this is a primarily physician audience, maybe some trainees that that you want to tell us?
Um, you know, it’s a really it’s a changing field
changing Really?
Yeah, that you know, there are more and more women in the field.
More and more people are getting involved in advocacy and public health and are really trying to be a part of injury prevention solutions. So in the same ways that cars were made safer through research and advocacy in the 50s and 60s that, you know, has drastically brought down the rate of injury and death due to Road Traffic incidences. physicians are just are trying to do the same sorts of things when it comes to violence, interpersonal violence, gun injuries, especially when it comes to children. And also things like elderly falls, which is the fastest growing mechanism for trauma. activation these days is elderly people who fall so a lot of your trauma surgeons are out there trying to come up with solutions to make your community safer. Not just the not just the Cowboys slinging scalpels in the emergency room.
Yeah, the social determinants of health, the things that are more likely that you will be the person that ends up in, in the trauma bay is something that that will have a far more powerful effect on the outcomes of the population, you know, minimizing how social determinants of health can affect outcomes, I guess, will have an outsized influence to, you know, our ability to suture,
right. And so, you know, ultimately we’re trying to put ourselves out of business through, you know, public health mechanisms. Yeah, another,
you’re not likely to happen anytime soon.
Well, but you know, you say that, but in Europe, for example, trauma surgeons are orthopedic surgeons, because the vast majority of trauma there is falls in Road Traffic incidents. And so the majority of injuries are orthopedic interesting, whereas in America, they have always been general surgeons because there’s an outsized proportion of interpersonal violence that needs immediate, you know, life saving intervention within the first hour of injury that is in the chest or abdomen or the peripheral vasculature. That’s why general that’s why general surgeons are trauma surgeons in the United States. So there’s examples across the globe of how, how we can do better how we can do better. Yeah, good way to put it.
See, I thought in Europe, they were they were all the surgeons were barbers, because they were the only ones with the sharp instruments
back in the day. Yes. But yeah, the trauma surgeons are the orthopods. Interesting.
So taking a little turn away from trauma surgery. I know you’re not No longer doing the podcast, but I loved it while it was around. And is there anything that you would like to mention that you learned from doing your podcast about medicine? from some of your guests? your podcast wasn’t about medicine, right? It was outside the operating room. It was all about what we do outside the operating room. So one or two highlights of your favorite interviews and you know, it doesn’t have to be mine.
I did learn a lot and
I think the
I think I needed the podcast more than any listener did. Because that helps me to remember that we’re all just human beings trying to do our best and what your best is, and my best is and somebody else’s best is not the same thing. So you know, one of my guests was a woman who, I mean, she just had it all and did it all and she had the the world’s greatest A CV, that every you know, college kid who wants to be a doctor would just dream of.
She hated it,
and was miserable and almost quit before she, you know, took a step back and found different ways to look at her life and what she wanted and how she was going to get there. And, you know, she’s still a very intense, very driven, very motivated person, but it was through having an executive coach and then becoming an executive coach that she was able to just put a different lens on her path and her motivation and what she ultimately wanted to get out of life. And it was enlightening for me to see somebody. You know, when we, when we think about, we see stories of people who change careers or who change who burned out, you know, terminal a burnout. You know, we think of people who like run off and be Yogi’s or run a smoothie shop or something. We don’t think of people who burn out and come back. And she burned out and came back even stronger in a way that was really, really motivating, really powerful to me. And she also reframed burnout for me a little bit in a way that I guess kind of unburden me a little bit of my own guilt, about, you know, the days when it’s hard to get going. So that was probably the thing that, that I was most impactful for me about doing the podcast. And like I said, I think I think I sought out the guests that I needed more than what anybody who might have been listening needed.
Doesn’t this is this is you’re basically saying my podcast right here, which is I just, I have questions. I would like them answered. And I figured if I’m interested in finding these answers than others, People are interested in finding these answers, but it’s still all about me. So
one has to be right. Because, you know, like, people don’t realize how much work this is, you know, you’ve got a wife and three kids and it’s nine o’clock at night. And here you are, you know, talking to a relative stranger on the other side of the country. It’s, it’s work, it’s fun work, but it’s work and it takes time. And so you have to get something out of it too.
But I think to what you were saying about the the burnout and and how you got something out of it. I think it’s it’s important to have these haven’t cultivate these outside interests. You know, I when I joined my practice, I was, I guess, 3332. And this was after that same training, the rest of us do, right, I went to college. I took a year off in between, I went to medical school, I did my residency. So every four or five years, you were onto something different. Mm hmm. I was hired. I got My job, had my exam rooms, and I looked at my exam rooms. And I said, Okay, so this is where I’m going to be for the next 38 years. Hmm.
And isn’t that horrifying,
like doing the same things over and over. And so you need to have those, those those other things. And you need to be able to evolve in your in your job, right, you need to be able to keep improving to know like, you know, keep going to conferences, keep reading, keep learning so that you can keep evolving. And it’s not the same thing. Because the way that I’m treating sinus infections now might not be the way that I’m treating them. 10 years from now, the way I’m doing sinus surgery now, there’s probably not going to be them doing sinus surgery 10 years from now, so you know, so improving your craft in this way. But also you got to have that outside stuff. You got to have the outside stuff. So you’re not just grinding and grinding and grinding and grinding and grinding. So there’s like a different, something just completely takes you out of that. And that’s that’s what it sounds like that’s what it was for you and that’s what it was. That’s what it is for me.
You know, and the, you know, the thing that my guests said the most, which, you know, I still kind of hold on to is that whatever it was that they were doing outside of the operating room, it made them a better doctor. Yeah. So, you know, we go through all that training and you know, I spent 11 years after college, and every single day, it was all about the patients, and it was all about the patients. And if it ever wasn’t about the patients, then you were wrong. And it’s got to be about the patient.
terrible person. Yeah.
Right. And you know, and then you lose what precious hours of sleep you might get, because you didn’t make it about the patients and it still is. But so many people acknowledged over and over and over again, that whatever they were doing made it easier to show up the next day refreshed or invigorated or whatever you want to call it, and able to make it about the patients because if you’re miserable, and all you’re thinking about is how you don’t want to be there then that can’t be about the patients either.
Yeah, the facts are wrong. Absolutely for sure. so wonderful. Well, I do miss your podcast. I hope you I hope you do manage to find find a way back to it but if you don’t know, I’m glad you’re finding the reason that you’re not doing it is because you don’t need it anymore. Because you found if you’re finding joy in other things in other ways like like hockey
absolutely that’s that’s where my my extra time goes now is being the world’s greatest amateur 36 year old female hockey player.
Fantastic and I love the that you drop that Slap Shot reference in our conversation before the show. What incredible movie incredible movie if you’re listening to you haven’t, and you’ve never seen it Paul Newman, the Hanson brothers.
Classic, most beautiful man to ever live Paul Newman.
Well, Dr. Stephanie strike. This has been a long time coming. I’m glad we were finally able to do this and it’s been a lot of fun.
Thanks, Brad. 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 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

Cutting the Crap on the Gut Microbiome with Frank Cusimano, PhD

Dr. Frank Cusimano, PhD, has a doctorate in Nutrition and Metabolic Biology from Columbia University and is currently a medical student at the Arizona College of Osteopathic medicine. Having done his PhD on the gut microbiome, a hot topic, we dive into the science of prebiotics, probiotics, postbiotics and antibiotics. What can we actually recommend to patients to help them with GI upset while on antibiotics? How does the microbiome influence inflammatory bowel disease? How can the gut actually influence our brains? A previous guest discussed how the colon is the window to the soul. Turns out there’s science behind that!

Having been a sponsored athlete as an adult, Dr. Cusimano is currently a medical student uniquely blending his understanding of biochemistry with human physiology and human potential. In college he received both a BS and BA from SMU in Chemistry and Biology and then went on to complete a MS from Johns Hopkins University in Biotechnology concentrating in Bioinformatics, all in addition to his PhD. He is the host of the Surviving Medicine Podcast and a regular contributor for Medscape and Doximity.

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

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Instagram: https://www.instagram.com/dr.cusimano/

Twitter: https://twitter.com/frank_cusimano

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Website: http://survivingmedicine.org/

Podcast: http://itunes.apple.com/us/podcast/surviving-medicine/id1276029472?mt=2

 

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. Frank Cusumano has a doctorate in nutrition and metabolic biology from Columbia University and is currently a medical student at the Arizona College of Osteopathic Medicine. Having done his PhD on the gut microbiome hot topic right now, we dive into the science of prebiotics, probiotics, post biotics and antibiotics. He teaches us what we can actually recommend to our patients to help them with gi upset while on antibiotics. How does the gut microbiome influence inflammatory bowel disease? How can the gut actually influence our brains? Now previous guests discussed how the colon is the window to the soul and turns out there science behind that, having been a sponsored athlete as an adult. Dr. Cusumano is currently a medical student uniquely blending his understanding of biochemistry with human physiology and human potential. In college, he received his BS in ma from SMU in chemistry and biology and then went on to complete an MS from Johns Hopkins in biotechnology concentrating in bioinformatics, all that in addition to his PhD from Columbia He’s the host of surviving medicine podcast and a regular contributor to medscape and doc SimCity.
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. Frank Cusumano.
Thanks so much for being on the podcast. Thank you. Thank you so much for having me on the podcast. It’s an honor.
Well, Antarctica. You’re welcome.
All right. So let’s get started. Give us the short version of your PhD thesis.
Yeah. So I guess I should have introduced with that or a second ago that when I say when you called me a doctor, a doctor Cusumano, technically it’s a it’s a PhD. So I have a doctorate in nutrition and metabolic biology, and I am in medical school. So I’m doing additional training. I’m a third year medical student, or seventh year, if you add the PhD to it, and I have my PhD is in nutrition and metabolic biology, and I’m uniquely trained in that and the only medical professional I will be the only medical professional with that specific PhD because it’s the only PhD of that kind that is housed in an institute of medicine, which is very unique, and that I was lucky and fortunate to be able to do that. But my PhD thesis was on the gut microbiome. So in the nutrition area, obviously, the bacteria in our stomach and in our small intestine colon played a huge role in the pathophysiology of many disease processes. But my specific topic that I worked on, you know, over the course of my PhD career was I engineered bacteria to modulate intestinal physiology, you know, deal with inflammation and also modulate behavior. You’re along the microbiome gut brain access. So specifically engineering bacteria to serve a specific physiological process in. For me, the most work that I did was in the large intestine.
So GMO for the gut microbiome,
essentially GMO for the gut microbiome, and that is the right way to think about it, because we were using genetically modified bacteria to serve specific purposes. I think
that’s gonna make some people’s head explode because you’ve got this whole, and we’re going to talk about this, but this whole area of pseudoscience, that’s that’s orbiting around the actual science, and these are a lot of hippie dippie people that are non GMO, and then they’re finding out that the person who’s one of their, you know, one of the people that they look up to because of the research that you’ve done in the gut microbiome, you’ve actually used GMO in this secret area of the gut microbiome. I think there’s some people that have head’s gonna explode. Okay, so can you give us any more detail about what that will do? I know there were, you know, for some time there was you weren’t actually talking to people about it because it was so Hush Hush.
Correct? Yeah, there was I mean, there’s still there’s patents filed on our research that we were doing. It was at Columbia University. The patents are have gone through so I can talk about it. We haven’t published our paper on it. We have a big one that’s in revisions that we were really excited about. So I may spare out some of the good details. But other than that, we’re going to talk about it. And I think when when I introduce the microbiome, when we talk about the microbiome, the microbiome is something that you know, is has to be specified for location. So when you’re talking about the microbiome, it’s just a collection of bacteria in genes that make up microbes, or any type of bacteria or fungi or Flora on a surface. And so I say gut microbiome, it’s specifically talking to the cashier intestinal tract, versus a colonic microbiome is just the microbiome found in the colon. And they all are very different. They serve different purposes. They have very different compositions. And they have very different genetic profiles. And I think that that’s more of the important part. The research is, as you said, rife with pseudoscience. And it’s it’s rife with pseudoscience, not for the specific reason that we think about pseudoscience and just being blatantly wrong. It’s that they’re early on microbiome research was very naive. And it was done in a way that our tools now are showing us that a lot of the regional research we did was not specific enough or it didn’t hone in on the level of specificity or detail on the research that we needed. Case in point that you may think about is none of the none of the labs doing microbiome research. actually started as microbiome research labs, they typically did not they started as gastroenterology s or gastroenterologist or microbiologists that wanted to do microbiome research. And so most of the P is the primary investigator. We’re not people that trained doing these techniques. I hear researchers talk about the gut microbiome extensively or you know, or medical professionals talk about the gut microbiome, and how they use it for all sorts of treatments. But when you ask them, if they’ve ever sequenced someone’s in fecal samples, if they’ve ever sequenced anyone’s gut microbiome, typically they’ll say no. And that’s the that’s the major issue that that I want, you know, people to understand is that the techniques and tools that we’re using to study the bacteria in your stomach, the tools are advancing so rapidly, that things that we were doing five years ago, are, you know, they’re not only rudimentary, but they give us misinformation. And so understanding where that misinformation lies, and it all comes down to sequencing techniques to genomic preps, to understanding how to analyze the data, the changes that we’re seeing in the past few years, just showed us that our initial findings were sometimes wrong. That’s the important part. I think for a lot of the microbiome research.
Well, there are labs out there that if you send them a sample of your gut microbiome, right, you give them a little fecal sample, they will tell you things about yourself. Like this is what you should be eating more of this is what you should be eating less of this is what diseases you’re at risk for. And that, to me sounds like there. That sounds like there could be some fear mongering and capitalization capitalizing on lack of science literacy, or am I just an old curmudgeon that don’t bully that doesn’t believe in new areas of science?
No, I mean, you’re not. Most of that is is accurate in your perspective. And those companies dealt with a lot of litigation already early on. And now they’re having to use specific wording or they’re having to do things in a specific way where they can’t talk about medical conditions, or they have to give it to a third party to talk about medical conditions. And the reason why is that, you know, we In 2007, the I think it was the NIH decided that they were going to put like 170 million dollars into understanding the gut microbiome so that we can understand what was best for patients. And what was the healthiest microbiome. And their conclusion after five years in 2012? Was that, you know, we spent 170 million dollars and all we decided was that there is no one correct microbiome. And in fact, it wasn’t which bacteria you have in your stomach. So when you when you send a sample to a lab to sequence your microbiome, they’re gonna tell you, not how many bacteria are, which bacteria are there, they’re going to tell you what relative ratio or population of bacteria are there and they’re only going to go as deep as maybe the genus level. But typically they stay at the family level or the phyla level. But the difference between two bacteria in the same genus is, you know, night and day. It’s not even the different I mean, it’s The difference between me and an elephant, like it’s really is that far. And what matters more is what genes are present in someone’s microbiome, right? So out of all the bacteria in your stomach, each bacteria has a number of genes, and they have, you know, their DNA, which genes are present and which ones are being transcribed, you know, translated into proteins that can do serve a specific function that is way more relevant than which bacteria are there, because the difference between, you know, an E. coli and your stomach for an E. coli in my stomach? Well, it depends a which genus is it? It depends which species is it, and then even to bacteria that are the same species, maybe as far as a rhino and an elephant, and the genes in those are so different that it’s really hard to say, and so that, you know, a lot of those tests, I would say, I don’t recommend for that reason.
So what are some other misconceptions that are out there about the gut microbiome?
Yeah, misconceptions. The gut microbiome is probably the most fun thing to go over, and a lot of it You know is is around fermented foods like probiotics everyone wants to know which probiotics they should take or if they’re useful well probiotic if you look at the definition of it, it’s a live organ microorganism that when you know taken an adequate amounts, it has some type of health benefit. Well, most bacteria over the counter probiotics don’t have a they haven’t been tested to show health benefits. And most of them aren’t living anymore, or they don’t reconstitute because most probiotics are pill forms and most pill forms, that means the bacteria has been life alized basically dried completely. When placed back into a host, they can come back and become active but over time, their efficacy drops drastically and a lot of them won’t survive the Trent, you know, the transition from your mouth all the way down to let’s say, your small intestine or colon, where your colon is actually where most bacteria are most useful. Most of the microbiome until you get to the colon. You know, it has some function and there’s depth events, some things that we’ve learned, but the majority of the bacteria that at least is beneficial, or that can provide a lot of metabolic benefits actually has to get all the way down to the colon, which studying that in humans is very difficult. So,
like if you go to GNC or CVS and buy probiotics, because you’re worried about getting an upset stomach, after antibiotics, or in the situation of myself and our listeners, you’re recommending that to your patients, what you’re ultimately recommending is dust. Right? So what’s contained in the pills of probiotics that you’re buying over the counter, laugh alized bacteria, that doesn’t make it to all the way to the place it needs to be. It doesn’t sound like that’s really what’s recommended, or that would be helpful in any way.
Correct. And this is where there’s a lot of good research on it, to show that most probiotics for almost every instance isn’t recommended because As a we either don’t know enough, or they haven’t shown any efficacy. I don’t take probiotics. I’ve been studying the microbiome, you know, for five plus years, but I don’t take a probiotic supplement. And if anything, the only thing I recommend to most people is just increase the amount of fiber in their diet. We all know about the different types of fibers, whether it’s soluble or insoluble, and they both have, you know, different motility benefits. But in terms of the gut has many different types of fiber that you can consume, feed the bacteria that are already there, and instead of focused on trying to introduce new strains or new bacteria from pills on the shelf, it’s more important to go to you know, the part of your grocery section where the vegetables are and buy different high fiber foods. Some of them are the ones that are high in you know, a fiber called inulin, which is one of polysaccharides that really does help your bacteria live that’s basically the food that they eat. In going to buy some foods like leeks or bananas or spinach or kale or onions or garlic, anything that can be used for your bacteria as food is actually way better than taking any pills over there on the shelf.
So what we should be telling our patients is if they’re on antibiotics, they should eat more fruits and vegetables.
Yes. And this is actually when they’re off antibiotics. They should also be eating more fruits and vegetables. Frank, this is groundbreaking. No, great. It’s totally groundbreaking. It’s actually really interesting. So it used to be that when someone gave someone antibiotics, the recommendation was to take a probiotic to help you know, your bacteria, bolster it up so that it could return after the antibiotics to, you know, to a faster position to you know, two papers came out from one of the one of the leading experts in this area, and they actually found that when you when you take an antibiotic, it does wipe out you know, a lot of the bacteria, but taking a probiotic along with that antibiotic actually delays progression of the bacteria coming back that you normally colonize. Why is that? Well, most probiotics that you take over the counter, don’t colonize your gut. Could they potentially be beneficial for a short period of time after you take them? Yes, there’s possible but the bacteria that is present after you take an antibiotic, you need to re you need to get that bacteria that’s still there that survived to the antibiotic, you need to get it to build up its amount and needed to replicate and to survive. And by introducing additional probiotics, what you’re doing is you’re basically competing it for resources. So think of it like, you know, like a war. If you get rid of half of the bad guys, if you get really rid of the majority of the good guys, you don’t want to throw more random soldiers that can’t speak the same language in there. No, what you want to do is you want to let the let the good ones you know, start to grow and repopulate and get back up to speed and that’s the best way to do it, is by increasing your fiber intake when you take a antibiotic to let the good bacteria grow and repopulate.
So this is completely different from any of the questions that I sent you but it just in a I don’t feel comfortable answering it, I completely understand. But with regards to the increasing fiber in your diet, there’s a lot of, there are a lot of fiber supplements. There’s a lot of food that has increased the amount of fiber from other sources, like protein bars with added fiber or fiber one makes a breakfast bar with added fiber. But it’s not like it’s like eating an apple where the fiber is innate to the food, it’s been extracted from somewhere and put somewhere else. Do you know if there’s any difference between actually eating it in in its raw form? versus have it having been extracted? Now we know what the hippie dippie answer is going to be, which is, yes, you should eat it in its natural form, if that’s the way it supposed to be. But ultimately, you know, does the gut know the difference between the fiber that starts out in an apple or the fiber that was extracted from an apple put in a breakfast bar and then consumed that way?
So this is a great question. And I love this question because it talks about you have to use real science to answer it, but it’s confusing. Science. And so I’ll try to explain this to the listeners taking exogenous fiber from any type of supplement powder or bar. For some reason in our gut, it doesn’t have the same effect as eating whole foods. Why is this? Okay, so So what the the conclusion has come from amongst most of the experts is that when you eat fiber, you’re doing it for mainly two reasons to feed the bacteria that are in your stomach. But also because fiber is broken down by bacteria in our stomach into beneficial secondary metabolites. Some of those are short chain fatty acids like butyrate eisah, theater a acetate propriate. In for some reason, those bacteria that produce the short chain fatty acids are that produce these beneficial secondary metabolites. They have to be present to do this. But people that don’t eat a naturally high fiber diet don’t have these bacteria present in high enough quantities to produce the benefits that you need from the secondary metabolites. So just taking you know having a poor diet you’re eating you know, No fiber in your diet, but taking a powder, it doesn’t actually serve the same benefit, you get added benefit if you can actually eat a high fiber diet. And then they see an additional benefit if they are taking fiber on a supplement form which typically in that case, it doesn’t eat it because you’re already eating the fiber. So you can’t eat McDonald’s and then put some Metamucil in your coca cola? Yeah, well, it may it may help you on a constipation front, but it won’t help you get the you know, it won’t help you, you know, establish a healthy gut microbiome and it won’t help you get the secondary benefit or the benefits from the secondary metabolites are being fibers getting converted by the bacteria to to produce, you know, the beneficial compounds
in your gut. But if you take some Metamucil and you’ve just eaten a salad, then that mute Metamucil is beneficial.
Correct? that’s what that’s what is implies in the Metamucil. I can’t remember what the exact formula in there with the fiber is. But the one that most of these research has been done On his insulin, which is typically the prebiotics that you see on the shelf, so when we’re talking about fiber, not only are we talking about the fiber for motility, but we’re mainly talking about what you consider on the shelf as prebiotics. And that is a term that’s been thrown around a lot recently, on shelves and on supplements and on the news has been way more beneficial than probiotics.
Okay, so. So what we should be recommending is, and this is where a place where I know you, you mentioned before the show, you’re reluctant to give, make recommendations because you’re still a medical student, but you do have a PhD. So what you’re saying, you’re recommending we eat more fruits and vegetables, but specifically, if the patients are looking to decrease their gi upset, they, they should they should do that more so maybe than they usually do. And I don’t think you should feel uncomfortable making that recommendation to anybody.
Yeah, I think. Yeah, there’s only about one or two really solid indications for adding probiotics and one that’s for the treatment of diarrhea resistant diarrhea in in, you know, adolescents or children. Probiotics have been shown to be pretty have pretty good efficacy, depending on which probiotic it is. So that’s still definitely an indication and I think PT pediatricians will know that. Although the research in the past few years has gone to say maybe that’s not the case, but I think the jury’s still out. So I would say that that’s still probably a general guideline that a lot of people are following. And then also, for patients that have C diff patients that have C. diff, that are receiving antibiotics, probiotics can prevent not only c diff, but they can also prevent the recurrence of people that have had c diff in the past. So I think that those are kind of the three main indications that we’re still seeing a good use of probiotics in a clinical setting. But other than that to patients that are having some gi upset let’s look at your your water intake, your your overall fiber intake and your fruits and vegetables and go from there as opposed to just recommending probiotics blank Need to say, Oh, well, probiotics gonna help your gut immediately, if that makes sense.
So you’d mentioned before, rather than consuming ly off alized bacteria to actually consume something that’s fermented. So there’s still bacteria in there. So what about things like yogurt or, you know, the big craze now as kombucha or maybe even a beer with still some yeast in the bottom? Right? What? What about consuming that directly?
So in most of the in most of the sense, most of those haven’t been shown to have good efficacy long term or in the clinical setting have not been shown to be effective at all. We see we hear that, you know, yogurts, great but when you look at the actual really good science that’s being done on these, we don’t see any benefit. And there hasn’t been there hasn’t been a good systematic review to show that the researchers conclusive that they’re beneficial. There’s actually most of them saying that they’re inconclusive and they haven’t helped at all or they’ve seen very little. Now most of the time for dairy based yogurts. The reason why they say they help motility is tends to be less from the bacteria that you’re introducing. But for patients that have constipation that take their yogurt help them, you know, have modal you know, better bowel movements, most of that tends to be because most patients are slightly lactose intolerant and so the dairy in there will instigate you to have a have a bowel movement, and that sometimes has been pretty has shown shown pretty good efficacy, but it’s not from the probiotics in the yogurt. It’s from that other side effects. Typically, yes, but it’s a beneficial side effect. So I don’t know if that’s most of the other fermented foods that we think about our you know, kimchi or kombucha, or Kieffer. Most of those To be honest, the benefit is in actual fiber that’s in those kombucha there’s almost none. So there’s your answer right there. They haven’t been shown to have good efficacy. There’s typically most computers as well. yeast and two different bacteria that you know, that colonized but do they pass the stomach with any efficacy there hasn’t been any good research showing it. fermented foods like kimchi Kimchi is actually one of the ones that I do recommend, but I recommend it to patients that are having issues or that have zero issues. patients that are kind of you know, want to increase increase the health of their microbiome, they can try Kim cheese and the benefits from Tim cheese typically is from the fiber that’s present in the cabbages that they typically using cheese. It’s not from the bacteria that’s being added. The bacteria that’s fermented in cheese is so little, and most of it is soil based bacteria, which typically tend to be good but they don’t they don’t survive very well in the acidic environment of the stomach, even though they’re locked in even though they’re lactate producing bacteria, they just don’t survive at a pH of two. So I tell people most people that consume kimchi I say if it if it helps you or if it’s great and it doesn’t upset your stomach, great, but if it does upset Your stomach, don’t think taking more of it is going to help just don’t eat it. Right? Because it is going to produce maybe some discomfort if it’s if it’s producing a lot of gas, which you know, some high fiber foods can produce gas and flatulence and if that’s a discomfort for you, then don’t worry about it because it’s not you’re going to get you’re not getting added benefit from it than just eating other types of fruits and vegetables.
Interesting. Interesting. So your your PhD thesis, you had mentioned the gut brain access, right? And this is another area that sounds more to me, like pseudoscience and science fiction. But thankfully, you’re on the show and you’re going to help to sort me out on this. So just explain to me what is the gut brain access, like how are these things actually communicating with each other? Although, Episode Number three, was with a gastroenterologist who says that the gut is the window to the soul. So you know you have agreement agreement With her on that, definitely so so just just help clarify what what that means because we’re we’re hearing that the gut microbiome can have an influence on issues like autism and Parkinson’s and dementia. So So how is that? Is that real? And if so, how is that possible?
So some of these are tricky, especially for the ones like Parkinson’s and dementia, the newer research is coming out is actually pretty good. But the initial research that’s showing these indications was actually very poorly done. And that’s because you also remember that a lot of this is a chicken in the egg phenomenon of is, is the, you know, what they typically do is they’ll sample 100 patients that have Parkinson’s and then 100 that don’t and they’ll say, Oh, well, these bacteria popped up as being the issue with people that have Parkinson’s. Well, are they present? Is that a chicken or an egg situation? Right? Was that were these the cause of Parkinson’s? Or are these just being predisposed to patients that already have Parkinson’s? Maybe for dietary or motility issues. Because remember, a lot of the gut is affected by the neurons, right? They there’s a term that the gut is a second brain. The guy who coined that phrase was actually the father of neuro gastroenterology. And that was Mike Kirsch on at Columbia who discovered the serotonin receptor in the gut. He was one of my, he was on the committee of my thesis. So he’s someone that I worked with closely. I spent three months in his lab talking to him about it, and kind of wrestling around some of these ideas, but also doing research on what the gut microbiome was affecting the neurons in the gastrointestinal tract. So the enteric nervous system. When you think about the gut brain access, most of it is a communication between anything that’s happening in the gastrointestinal system with the brain. That could be anything from that can be modulated through the neurons through the parasympathetic nervous system through the sympathetic nervous system, through the defense of a ferentz and then also through systemic circulation. Most of the systemic circulation isn’t we originally didn’t think was that much because Most of this is neuron based right? And something like serotonin or something like dopa mean. Most of those won’t survive that long and systemic circulation right for serotonin platelets take it up. And then it doesn’t cross the blood brain barrier. But there are things that are right. One of the precursors of serotonin is tryptophan, tryptophan, when you eat it, it gets absorbed and increasing higher amounts of tryptophan can increase the amount of tryptophan in the brain. And that’s kind of one of these fundamental areas of research right now is trying to figure out from a nutritional standpoint, what we can modulate to affect the brain, some fundamental or some kind of pivotal research went back. Back from McMaster, I think it was back in 2011 or 2013. And that’s when they figured out that one of the major implications between the gut and the brain is the Vegas nerve, right? We all remember learning about the vagus nerve but vaguely remember about its role in the gut. Well, the vagus nerve has He has projections all the way to the V Lie of the small intestine and the colon. And when you sever the vagus nerve in an animal model and you feed it certain bacteria versus not, you do see changes in the brain, that have been recapitulated with specific bacteria. Now, there’s only one that they’re thinking has real proof of being clinically useful. But their clinical trials that they’ve been using for this bacteria, which called JB one hasn’t been shown to have good effect in humans, but in mice, they see that the level of the gamma receptor does increase in can’t remember the exact same spot of the brain. But that is one area that they’re that they’re looking at the research that I was doing was your weight. You’re
losing me here, you’re losing me here. What’s the significance of that?
So the significance of it is that there are bacteria that could have effects on the brain through the vagus nerve. That is an area that we should really think about and really say okay, are there other bacteria that can do this, how is the bacteria doing this? We don’t necessarily know. But we have to remember that when you think about the bacteria in your stomach, it’s not the bacteria isn’t totally wiped out from, you know, if it’s in your gut, then it’s beneficial bacteria depends on the location of where the bacteria is. So certain bacteria aren’t, they don’t have no efficacy for having any benefits to the gut unless you put them right up against the epithelial layer where they can interact with some of these neuronal projections that are that are between the epithelial cells of the gut. And that’s the that’s the things that we’re learning and that we’re now doing research on that we didn’t do five years ago, because we didn’t have the tools. We didn’t have the knowledge and we didn’t have the understanding to be able to do that.
Then how does it get so so it’s influencing the vagus nerve, but then how does that translate into something like dementia? That seems to me like such a big leap? Yeah, correctly, I would think it would, the bacteria might have Something to do with you know, the parasympathetic nervous system and gut motility, but specifically influencing brain activity, like complex centers of the brain, I just don’t see that. I can’t I can’t make that leap. And that’s I also don’t have the the physiology background of a lot of the stuff that you’re discussing. So it is it is a little harder for me to follow. But But still, I just can you help us get there?
Yeah. So that’s the hard part is I think that we there’s still a lot of areas that we don’t know, we don’t know how it’s making that now we, we know that on the neuronal side of the GI of the GI system, there are specific bacteria that can increase the amount of neurons in the gut. So that means that they’re increasing. How many neurons make up the main turret Plexus or the Auerbach’s Plexus in the intestine that helps with motility now translating that up through the vagus nerve or up through the parasympathetic nervous system to the brain to create neuronal changes in the brain. That is where we typically fall short. And there are some researchers that are trying to do it live in Italy. There’s there’s good research, and there’s also want to do that trying to do this. But your questions are good to have, because I think that your skepticism is a skepticism we need in science because we’re not finding, for example, the bacteria that I was working on, we haven’t figured out directly we saw some behavioral issues. But when we say behavioral issues because of probiotics that we’ve engineered to do stuff, yes, we know what it’s doing in the gut. But on the brain, we don’t know what it’s doing. And we don’t know where it’s having these effects. Maybe it could be having these effects because it’s affecting motility. And as you know, as anybody knows, go through have diarrhea for five days. And next thing you know, you feel terrible, you can’t sleep properly, you’re up at night, you have a little bit more anxiety or a little more high stress, or vice versa. You can’t prove For a few days, and now you’re stressed out, your stomach hurts, you’re not eating as much you’re trying to drink. But these issues fundamentally do affect our emotion and our behavior. But it may not be as much as just directly affecting a specific spot in the brain, if that makes sense.
Yeah. Yeah. So it seems like my follow up question is, is there evidence in using probiotics to alter or prevent disease in these non bowel diseases? We’re still in our infancy and learning about them. So to think that we can take something, especially after all you said about probiotics. It doesn’t it doesn’t seem like we’re there yet. But what about for bowel diseases? Right. What is the effect of the gut microbiome on say inflammatory bowel disease?
Yeah, for inflammatory bowel disease. I think that there’s been some trials that have that have shown that, you know, some of the probiotics work or could help and then in the majority of them, there hasn’t been so I think the most recent reviews that they’ve done for inflammatory bowel disease. Were there Crohn’s or ulcerative colitis, probiotics haven’t been shown to have a big effect. Why is that? Well, you have to think when someone has inflammatory bowel disease, you’re not just thinking about the bacteria in there, the the tissues inflamed, right? The immune cells are activated. And the area that Everyone misses, whether in gastroenterology or not, is the mucosal layer that protects protects the epithelial lining of the GI tract. If that mucosal layer is degraded, or it’s completely destroyed, because in inflammatory bowel disease, a lot of cases it’s completely destroyed. Throwing back probiotics at it isn’t going to help. You need to let the actual cells heal. Let the epithelial cells heal and then you need to have them build back up their mucosal layer for the bacteria to live because mostly bacteria live in the mucosal layer, not, you know, right up against the epithelial cells. Does that make sense? That’s really interesting because
as an otolaryngologist, we think a lot about the size of the sinuses. mucosa ciliary flow and a lot of what you’re trying to do is restore mucosa, ciliary flow, and that mucus blanket and the direction that the cilia are pushing it. So, in this, this is an era ago, we used to just strip away the sinuses and remove the mucosa and think that you remove the disease, but then it gets replaced with scar and you just you need that mucosa and you need that mucus layer.
Yeah, yeah, well, you need you not only need that mucus layer in the gut, that bacteria actually eat that mucosal layer, right there specific bacteria like Akram, Anthea, you could send affiliates that actually use that mucosa layer as a new nutrient source. So if that’s not present, these bacteria aren’t going to be very happy or they’re not going to be able to thrive. And they’ve actually some newer research is showing out that patients that are in the ICU, that have some of this degradation of the mucosal layer, giving them probiotic, this actually could increase their risk. Have septicemia Now you may be thinking, Okay, the link, the link between taking a probiotic and getting it into your blood system seems like that would never happen. But if you look in PubMed, there are multiple articles now proving that it’s the same exact strains with some modifications that have gotten from probiotic form into the blood system of some of these patients, where that’s happening, how that’s happening. I think that there’s still a lot of room for explanation. I think the science is still at its infancy. But that’s an area that this idea of just throwing probiotics or bacteria or trying to make the microbiome more robust. I think there’s going to be some times where we have to pump the brakes and think about, okay, what are the real indications? And what are the potential cause or harm that we’re doing, you know, recommending these or taking these on patients that maybe don’t need it?
But it sounds like it ties into what you said earlier about introducing the probiotic actually being competition that you’re introducing rather than improving the function of the backend. that’s already there. Exam sounds like that sounds like what they’re doing what they tried to do with the best of intentions in the ICU.
Yeah. And when I when I’m saying this a lot of it’s from specific strains. Now there are strains out there that researchers are looking at specific ones that could help patients with pouch itis or patients with inflammatory bowel disease. Those are specific strains. They’re not, you know, are there specific species, they’re not just a blanket over the counter recommendation. And so those until one of those is approved by the FDA, as that a probiotic on the species level is being recommended for a specific disease process. Until we get there the row the science is not robust enough to recommend it for most diseases except the you know, the indications that I mentioned earlier.
Yeah. So something that we had talked about before that I want to definitely don’t want to miss is antibiotics. Right? So antibiotics, we were concerned about antibiotic resistance. We’re concerned about gi upset. We’re concerned about C. diff. But you had mentioned there are some other unintended consequences of antibiotics. So could you discuss that?
Yeah, the unintended consequences, I think actually mentioned in a roundabout way, and that is that mostly antibiotics will basically slough off the mucosal layer of the gastrointestinal tract, or they have unintended consequences of patients that take antibiotics for years at younger ages are at increased risk of having metabolic syndrome or having increased risk of having obesity or type two diabetes. Some of these we’re not sure why now, there’s a lot of theories and a lot of research that’s indicating that it could be a meta genome level. So some antibiotics may affect the meta genome in the epithelium of the gastrointestinal tract that’s translating to the pancreas and translating to the liver. And then there’s other research that indicating that using antibiotics for long periods of time can affect the amount of short chain fatty acids that are produced later in life, which is basically the beneficial secondary metabolites that our bacteria produce, to actually give us benefit. doing that, you know, for a long period of time is really you know, damaging.
So one thing that we also talked about before the show is your your lifestyle choice. You are plant based, and again, being an old fogy myself. I’m only 40 But still, the term plant based for me is new and I have no idea what the difference is between plant based and vegetarian or plant based and vegan. I know the difference between vegan and vegetarian. I understand enough about that. But this new term plant based to me sounds like someone who mostly eat plants, but couldn’t quite give up bacon. Or it’s a vegetarian with a PR problem. Right? Like, like prunes prunes have a PR problem. So they tried to rename themselves dried plums and it didn’t work out so well for them because still prunes but plant based may may be a little stick stickier. So so you describe yourself as plant based. What does that mean to you? And what does that mean to the public?
Yeah, so so first before we talk about this issue, one of the things that I do want to set straight is there’s now in the news, a lot of hype for plant based or veganism, especially because a lot of documentaries are, you know, the advocates that are really pushing for it. Now, I’ve been plant based for over 10 years. And so when I say I’ve been plant based, it’s not because it’s a fad, or it’s not something that you know, happened overnight and I want to talk about it. I’ve been playing bass for 10 years and I don’t talk about it that much, because that’s just a part of my lifestyle who I am. What is the difference between plant based veganism and vegetarianism? So plant based, it used to be that plant based was someone who was vegan, who chose not to be associated with the PR issue with veganism or vegetarianism. plant based was you know, fully vegan, no animal products. It was no no meats or no cheeses. It was just fruits, vegetables. Nuts seeds, whole grains, beans, lagoons those specific nutrients and it was a focus on eating whole foods as opposed to eating processed foods. So you can obviously be vegan or vegetarian and eat only processed foods right? You can buy those at the grocery store whereas plant based was focusing on whole food plant based foods. Good
example is Oreos are vegan.
Correct? Exactly. Oreos are vegan, but would it fall into plant based? Well, I mean it depends how strictly you’re you’re saying your whole foot whole food plant based vegan person, you know follows that diet. Now the difference between vegan and vegetarian is obviously the difference between dairy consumption cheeses and milk. And then there’s a lacto ovo vegetarians that consume eggs. And then some people will say they’re vegetarian but they’re more pescetarian and occasionally have fish but plant based now in the past probably six months because of the the hype of the word plant based. It has now a lot of people Do consume animal products, whether they’re it’s, you know, chicken or whether it’s bacon, or whether it’s fish associated themselves with dog plant based because they say oh, and primarily plant based. And they do deviate from being strictly plant based, if that makes sense. So I think that the, the terminology is so new that a lot of people don’t necessarily know where they fall. I just say plant based because it doesn’t turn heads. And if I say vegan, everyone thinks I’m gonna yell at them because they’re wearing leather. I prefer when, but that’s not my focus at all. My focus is typically on on just the food, and it’s for the reason of most of the science that I’ve studied.
So you’re plant based because you want to be left alone. All right, everybody, please take the hint. When you see Frank at a restaurant, just you can ask him for his autograph. Please. Don’t harass him about his food choices. He’s plant based. Leave him alone.
Yeah, and my wife laughs because my wife I mean, she’s an omnivore but she’s jokes and she tells everyone she’s a carnivore, and she does that specifically Because she thinks it’s funny, I’m playing bass, she’s carnivore, she doesn’t follow the same diet, and it has never really gotten in the way of our relationship we’ve been married for over four years. And that really hasn’t been an issue. So the idea that it’s a stigma that it’s, you know, as political as left first write isn’t necessarily the case for everyone.
You do what works for you, and leave you alone.
Exactly. Right. Well, is
there anything related to the gut microbiome that we haven’t discussed yet that you think bears mentioning?
I mean, there’s obviously a ton of research that could be mentioned, right? We know that the microbiome is affected by certain things in in our diet, whether that’s the amount of Coleen or the amount of carnitine that someone’s consuming and that gets converted by the bacteria in our stomach to TMA which then in our liver gets converted to tmo, which now baby maybe a new linker for cardiovascular disease or some other illnesses. A lot of the sciences pretty good is pretty good and pretty robust on it. But using it as a clinical indicator hasn’t been hasn’t been established well enough yet. But I think that there’s there are a ton of topics that we could obviously talk about and go over. I would I would kind of be more interested in just to tell people that if they are interested, if they have questions about the gut microbiome, they can always email me or asked me, obviously, I’m a medical student. So I’m busy. I’m studying a lot. And I’m actually still working on papers, I’m still doing additional research, which as anyone knows, in the medical profession is difficult to balance. But I’m happy to answer other questions if you have any specific ones. And you must be so tired all the time from not eating any meat.
That’s what they say. But you know, for
just kidding, I’m just kidding. I’m just
so yeah, well, I mean, I think that that’s actually a great area that people need to be wary of is most people that transition to this day, under consume calories drastically. And if they’re plant curious or they’re eating curious or whatever, most of them, just don’t consume enough calories, whereas if you consume enough calories, I mean, it could really, it actually is the opposite. He can have a huge energy boost. But you know, it really just depends on on hair consuming, but you don’t I mean, this isn’t necessarily the healthiest way for everyone. And I tell people that because it depends on what level of scrutiny, you’re gonna look at your food. And if you’re just removing things and not replacing it with other things, and you’re going to have real issues.
And be sure to send a sample of your poop to an unlicensed lab so they can tell you what diet you should be using. And
take your mind zactly. Exactly.
Right. So where can people find you online?
Yeah, if they want to find me online, I have both a personal Twitter and Instagram, Twitter, I’m not that active on Instagram a little bit more active. And I share some of the science. I don’t give medical advice, but I share some of the science about what some of the newer research is showing or where it’s going in the nutrition front and microbiome front. If you’re interested. I do have a medical podcast as well. It’s not we don’t talk anything about the gut microbiome. We never really When talking about plant based really except a few episodes, majority of it are for medical students and for residents where we interview physicians or residents that are about to finish their training and talk to them about the medical education process. It’s called surviving medicine because we all know medicine is hard. It takes a lot of time it takes a lot out of you and burnouts a real issue. So we discussed topics like that on our on our podcast, but it’s typically only focused on that, that that area, but from every different specialty, and then been the links, I’m sure there’ll be in your show notes, but that is surviving medicine.org there’s five more minutes in podcasts and on Instagram, that’s surviving dot medicine. If you look us up, you can find this.
Dr. Frank Cusumano. Congratulations on the PhD and thanks so much for being on the show. Thank you 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 web page. Also, please be sure to leave a five star review on your preferred podcast platform. We’ll see you next time on the physicians guide to doctoring.
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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

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

 

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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 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

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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.

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

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

 

EPISODE TRANSCRIPT

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

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.
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