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#20(S2) TALKING TO YOUR DOCTOR with North York General Hospital CEO Dr. Joshua Tepper

#20(S2) TALKING TO YOUR DOCTOR with North York General Hospital CEO Dr. Joshua Tepper

Talk About Talk - Executive & Leadership Communication Skills

June 11, 201947m 8s

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Show Notes

Dr. Joshua Tepper, CEO of North York General Hospital, shares advice on how to talk to your doctor, including: come prepared with a list; ask lots of questions; if you’re Googling your symptoms, consider the quality of your sources; and lots more!  We have all felt unsure, and some of us have felt awkward around our doctor.  Here is our chance to learn how to optimize our communication with our doctors so we can receive the best medical care.

 

References & Links

Dr. Joshua Tepper & North York General Hospital

Medical Resources & References

Other Resources & References

Talk About Talk

 

Interview Transcript

Dr. Andrea Wojnicki: Thank you very, very much for joining us and sharing your expertise on how to talk to your doctor.

Dr. Joshua Tepper: Good morning. Thanks for having me.

AW: So I’m going to start with a very basic question. What do doctors wish patients would do in preparation for and during an appointment?

JT: First of all, we just want people to come in and see us when they need to. We wouldn’t want people at the end of this to feel deterred, because there’s all this work to do. Ultimately, if you’re not feeling great, or you have questions, just come and see us. But it is helpful if you can give a little bit of thought ahead of time to

what you need out of that appointment. What are the important things? I increasingly have patients make lists for me. And those lists are really helpful. And then when you actually come into the appointment, you pull up the list and use it. I’m not upset that you made a list. So pull it out and use it and start with the most important things.

AW: Okay. Okay, so you said at the beginning, “don’t hesitate to make an appointment.” And I have to tell you personally, and I’ve heard this from other people, “well, should I make an appointment? No, I’ll be fine. The doctor will think it’s nothing, I’m wasting their time, I’m wasting resources…” How do you know when to make an appointment?

JT: You know, I think you have to be your own best judge. And it’s more important to err on the side of caution. And the other thing is, even if it turns out to be physically not important, if it’s emotionally distressing for you, that’s enough reason to come in just for the mental reassurance. I don’t want you at home worrying for three weeks, I want you to come in and have this conversation.

AW: Right. So a written list.

JT: Yeah, I mean, written on your phone, whatever.

AW: Right.

JT: But it is helpful because I do that before coming in…  like you and I today, you thought ahead of time about the questions to make this process go smoother.  And it just makes this interaction go a lot smoother. And you know, you’re getting the important stuff out.

AW: One of the things that I’ve started to do, actually, partly because I have three kids, and I’m managing their healthcare as well, is I’m keeping a list in my phone of all the appointments that we’ve had. And I’ve personally found that to be really helpful. Because when you’re in the moment, and they’re asking you questions about

the health history, about previous appointments, I have dates and everything all. there So I guess that that’s part of that too.

JT: Right. The other thing… Two other quick thoughts. One, I think more and more in the future, we’re going to see what’s called asynchronous appointments, meaning text messages, emails, phone calls. We have not had a lot of that in healthcare in Canada right now, right? But in the United States, places like Kaiser, 50% of their interactions are digital and largely asynchronous. So you can have digital live skyping type things. But these are texts back and forth. And that will really encourage people to say, “Listen, this is happening. Should I come in or not?”  And I now text with a lot of my patients through secure means and email. And again, we can triage. And the one other clarification is you shouldn’t wait until you have a full list. If they are truly minor for you, that’s fine. But I don’t want people to take away that you have to have a list before you come in.

AW: You can come in with just one thing, right?

JT: The list could be one.

AW: I think about your point about prioritizing as well. So, tell the doctor first what your primary concern is, and then go down the list.

JT: And then what I do, what I think especially when I see a list, is, “Oh, this is good.” And so they may say, “oh this is the first thing on my list.” And what I’ll often do is say “why don’t you don’t just read me your whole list,?” Because then I can actually help prioritize as well. Because the worst thing for me is when I spent  my 15-20 minutes with somebody, talking about their tennis elbow, or whatever it is. And then they say, “okay, and by the way, there’s been this horrible chest pain as well, when I play tennis.” And like  maybe we should have started with that. And so if I see a list, I’ll often just say, this is great, tell me what else is on the list quickly. And then I’ll say what’s most important to you? And if it aligns with what I’m hearing, I’ll say great.

AW: I’ve also heard that sometimes I guess, depending on what type of appointment you have, that bringing a friend or family member can be a good idea, what do you think about that?

JT: Absolutely. I’m very open to that. I just always try to make sure it’s true to what the patient wants, what I don’t want, especially sometimes with teenagers, or even elderly people that this is truly voluntary? – the other person in the room? As opposed to somebody else intruding into that. And so I will try to just find a quick moment to really just say, “would you like this person here?” In case there’s something they didn’t want to say in front of their partner. Because it can be hard. Somebody said, “Oh, I’ll totally come with you.” What do you say? No, like it said, it feels like a generous offer. So I’m very open to it. I just try, as a physician, to assess, is this truly what the patient wants? Or is somebody else inserting themselves?

AW: It can be very helpful to help remember things.

JT: It can be very helpful for the patients who have memory issues or who are anxious or confused. And especially from mental health, and I have a lot of patients who have very severe mental health problems, it can be really helpful.

AW: I think your point about it being common for teens, and for older people, to have someone with them, and not necessarily have that person be welcome in the patient’s mind is a great one.

JT: And again, sometimes that physical exam is a time when I can then be along for the patient. And I’ll say, “okay, Mom, why don’t you step out?” And then when I’m taking the blood pressure and listening to the lungs or examining the knee or the ankle, or whatever it is, it’s just a chance for me to ask a few other questions or just open the door and say, “Oh  was there anything else you were hoping we could chat about?” And that’s when things like I’m worried about my acne, I’m worried about sex, I’m worried about  birth control, all these things, or I have a question. Just try to create that space and see what happens and they otherwise might not come up.

AW: Is there anything that patients do with some regularity that make you roll your eyes? Or that you just wish …

JT: Honestly? No, I mean, I  honestly, I think patients,… my experience is just patients are generally quite grateful and appreciative and thoughtful. And when I find they’re not, when they’re angry, or they’re

quote, unquote, demanding  it’s usually coming from a place that I can understand  they’re in pain, they’re suffering, they’re depressed, they’re anxious, they’re in a state of crisis. I understand,

why this behavior is what it is? And is it pleasant to receive? No, but it’s not personal to me. It’s reflective of the way this person is, unfortunately, in that moment. And so no. One of the best parts about medicine is it’s a people profession, for the most part, and you have to like people and be present with them and be where they’re at.

AW: So talk to me about the Google effect. People are self-diagnosing, from googling their symptoms on the internet.

 JT: It doesn’t drive me nuts. It’s modern healthcare in modern society, right? People are checking you out before they go into a restaurant people are going on to the Facebook pages of organizations, people are going on to websites, people are googling every aspect of their life to try to inform themselves better. From where they want a burger, to who’s going to be their heart surgeon. And so why would I suddenly expect them to use the vast internet for every part of their life: for buying a house; searching for mortgage; and then suddenly, on something that’s so important to them, like their health, they’re gonna be like, “oh, now I’m not going to use the internet,” right? That’s not what I would do as a patient. Or why would I expect them to suddenly isolate information from themselves? What I do though, is I try to guide them towards good sites.

AW: Okay

JT: I try to help them curate the web. You know, I think the challenge for all of us on the internet is, what website do you go to? Do you go to Yelp? Or do you go to this? Or do you go to that you go to  and so I do try to recommend to my patients and help them navigate the web and curate. And so if they’re worried about vaccinations, I’ll say these are the two or three websites, I really recommend that you go to the Public Health Agency of Canada, the Center for Disease Control, if they have questions about cancer treatment, or screening, I’ll say go to Cancer Care, Ontario’s website, so I do try to help them curate and navigate.

AW: So it sounds as if, based on other conversations I’ve had with other doctors that you may be a little bit more enlightened in terms of being open to patients coming in and being informed to some extent from internet sources. But I’m also hearing that, if you’re going to do that, make sure you’re on quality, non- “fake-news” websites. Can you share with us what are some of the more highly regarded ones that are more, for example, grounded in science?

JT: Yeah. So you know, just one quick point, I don’t know if I’m more enlightened, or more realistic,….

AW: Also more humble.

JT: But it used to be not “Oh, I went to this website…” No. It was, “oh, I was at a party last night and such and such said this” or “I was talking to my mom,” right? Chatting with my neighbor. People have always solicited outside information. Now it’s just easier, and there’s more of it. But people would always come in and say, Oh  you gave me this. But my aunt always says it’s much better to use this. Now, it’s not their aunt, it’s somebody on a chat room over in some other country.

AW: Right.

JT: But this idea that people are still living getting third party information of various levels of quality. And other times, I remember people coming in saying, actually, my dad’s a neurosurgeon down in Texas, and naturally, he wondered about this-and-this and you’re like, Okay. That’s like going to a better website, than your, whatever, neighbour who’s had a couple of drinks and has a view of your rash. So the point is, there’s the fact that people have always solicited outside information and advice is not new. It’s just now it’s digital. And there’s more of it.

AW: So when patients are sharing the information that they have with their doctor, they should tell them the source.

JT: Yes, I think it’s helpful when people say I was reading, I always say, oh, were you reading that online? Or tell me more? What website? And then that leads to your question about what websites do I recommend

I typically do like publicly funded, typically, government type sites, like the Center for Disease Control, or the Public Health Agency of Canada type agencies. People are incredibly sophisticated these days. And so people will go and even read medical journals now because they’re online, and a lot of them are free, or don’t pay five bucks for the article or three bucks for the article. And so again, some of the I’ll talk about if you’re interested in that, people are very specific. You’ve got a PhD yourself, right? You’re very capable of navigating some fairly sophisticated material. But I might say – if you’re interested in this, here’s three or four journals, and you’re going to go and spend a bunch of money on buying a couple articles about a health issue. Here’s a couple journals that we think are really reputable journals. And so we’ll have that. What I say is – Be very careful about online blogs, or opinions.

AW: So, when we’re reading the news, we try to always have in the back of our mind to be careful, right, in terms of considering the source, and not falling for the clickbait. And I know that the clickbait exists out there in the medical websites or the opinion websites that are masquerading as medical websites. So that’s, that’s a great point. Just to shift gears a little bit. I’m a big fan of Atul Gawande. And in his book Being Mortal, he highlights that hope is not a plan. And I was re-reading in preparation for this interview, one of the things that I read said that he means that for both the patient as well as the doctor or the care provider.

JT: right

AW: that hope is not a plan. And so this is a question, it’s a little bit turning the original question on its head, but how can we as patients, encourage our doctors to be as open and forthcoming as possible? We know that it’s important for us to be open and transparent and thorough in what we’re communicating. But we also want the doctor to be the same way, how can we encourage them to do that?

JT: That’s a great question, actually. And it’s funny, I spend most of my time on this as a physician thinking, How do I create a safe space for people to talk openly and feel they can share? whatever it is they need to? But it’s a, it’s a good question. What allows me to be as open and forthright?  You know, one is to ask questions, because your questions, will push me farther in thinking through and sharing. And so the more questions you ask, the more it will prompt me to be fully disclosing. And it can be open ended question – is there anything else I should be thinking about? Is there anything else that other patients who are in my situation might also have asked? – Things that will broaden my mind to giving you more information. You know, simply saying  I’m somebody who likes to know all the risks, I’m somebody who likes to have as much information as possible. So if there’s anything else you’d like to tell me, I really, I’d be very open to it. I tried to do that for you as a patient, is there anything else today? These can be hard conversations, but I want you to feel comfortable talking about these things. Things like that. You can flip it back, if you will, and so to say, is there anything else you think I should know? I’m somebody who likes to have a lot of information, etc.? Is there anything else? Are there any risks? Is there any other options or risks? Is there anything else? This could be beyond what we’ve talked about?

AW: I feel like some of these questions might be good things to add to our list before we come into the doctor. Right?

JT: Yeah, I think they can be. Now, again, these are follow up questions to a specific issue. So as opposed to open-ended questions. They are more like – Okay, I’m coming in with these headaches. And now, as we talked about the headaches here – some ways of broadening that conversation.

AW: Okay, here is the ultimate question. We all know that we should tell our doctors, everything. We should not be shy. And we’ve all heard that “doctors have seen it all.” Right? It’s basically become a cliché. But many of us are still hesitant and embarrassed to tell our doctors everything. Do you have any advice for patients on how to get over the embarrassment of sharing everything?  Peeing in a cup, seeing me naked, whatever the horrible thing is that they don’t want to talk about?

JT:   A lot of it does rest with, to some degree, the physician and the health care structures. I’d like to think we’re getting better at some of this stuff. I’d like to use those two examples. I remember when I was in training  we sort of had people that come in the room and pointing down the hall, and they’d carry the cup down the hall with them. And actually, now in my clinic, those cups are all in the bathroom. You can just go into the bathroom and take the cup from there. And then there’s a little door that you can put it in. I remember when I was in training that we used to write notes, and the patient would step behind the curtain and change. And now I just completely leave the room, and give them total space, as opposed to just sort of drawing this curtain and pretending I didn’t know they were undressing on the other side – or knowing, but ignoring it. And so I think we’re much better, hopefully, at prompting questions. The questions they ask now. And how I ask them. Before, I might have said things like, “do you have any concerns about your sex life? Or are you sexually active?” And now I asked questions like, “are you sexually active with men, women or both?” We are much more explicit.  Now these days, especially in the populations I serve, when I first meet patients, I’m like, “Oh, hi  I see your name is Andrea, how do you like to be identified and called?” And for somebody who never would have – or might have taken years for them to get to the point of saying, “actually, I’m not sure where I identify as a man or a woman or where I am on this gender fluid thing.” I’ve suddenly created a space in the very first moment. And even if at that moment, they said, “Well, no, Andrea,” they know, I planted a seed that next time they can come back and say, “actually, it’s more Andrew.“ Right? Or I’ve wondered, and you just create an openness. Or ask questions. I used to just say, “oh, how are things at home? You know, are you married or not married?”

AW: Right.

JT: And I would say, “what are your living arrangements? Do you have any concerns with intimate partner violence? Be it like physical, verbal?” When I ask, I try to create space for the uncomfortable. And if people look embarrassed, I say, “I ask everybody.” Right? I ask this to everybody.

AW: And now everybody wants to be your patient, Dr. Tepper.

JT: No, I don’t know about that. But it is, it is trying to give permission for these hard conversations. It is trying to anticipate what people may not want to talk to them about. And creating that opening. And even if they don’t take that opening today, they might take it in six months or a year. Or you know, it’s just trying to allow, to create a really safe space. And then I think  for patients, it’s just – what is what is keeping you from sharing? And sometimes it is just that physical embarrassment.

AW: I think oftentimes, it must be right?

JT: I think it is, but other times, it’s where’s this information going to go? And especially now that you see us, you have seen us writing, but actually now, for better, for worse, it’s typing into a screen. And we all have this sense of – where the heck does this data go? And who has access and we read about files being lost? And so if it’s just pure embarrassment, that’s one thing. But if it is a concern about data, you should ask , “if I tell you about this, who else knows? Who else has access to this chart? I see these notes. Who else gets to read these, right? If that’s part of what’s driving your reluctance, it’s fair to inquire. And then, in fact, a lot of our charts can have what are called black boxes. And so we can black box certain information. So patients can say, “Listen  I don’t care if you know about my peeing and my pooing, whatever. But when it comes to whatever this is, I want this black boxed.”

AW: Ok

JT: And we have ways of sort of carving and locking certain information differently than other information.

AW: I hadn’t heard of that.

JT: Yeah.

AW: If you had a family member who was having health issues, but told you in confidence that they were shy about talking to their doctor about it? How would you coach them in terms of their mindset going into the doctor to be more transparent about their questions?

JT: Yeah, I think it would be, why are they shy? Is it something about that how that physician or nurse practitioner  has interacted with you previously, that has made you shy? Did they act in a way that made you feel like judged or judgmental? Did you talk about sex toys, for example? And they seemed to react uncomfortably? So now you don’t want to talk at all about anything about your sex life? When in fact, you have all these questions about you know, how to clean them, the risk of sexually transmitted diseases and sharing sex toys,… Maybe there’s a whole range of questions you have now. But you felt judged.  Is it something about what the providers created a space for? Or is it actually just you have a hard time? In which case I say, this is important. Just ask it. And if you need to use euphemisms, sometimes what I’ve asked patients, when I can tell them is this: write it out. Just give me a letter, send me an email.

AW: that’s a great idea.

JT: So I have had patients write me very detailed letters, draw me pictures, write out letters. And I’ve just sat there. They’ve literally walked in to the next appointment. And often when people are talking about very difficult things – around spousal tension, and they just feel they’re betraying their spouse or they don’t, they can’t talk about it without getting too emotional. And they’re too embarrassed to talk about it. They can write me a letter, and they’ll drop it off ahead, or they’ll come in and I’ll hand it to me, and I’ll just read it. And then

I’ll thank them for sharing it. So often when it’s hard to talk about, it you can write it out.

AW: That is great advice. And I heard you say something previously, I think, if a doctor is making you feel that uncomfortable, that you’re feeling judged, you probably need to get a new doctor.

JT: Yeah, I think or if you’re confident enough to say, if you feel like you can engage. Like I had a patient once come in and say to me, like, we talked about this last time, and I really felt you didn’t hear me, or you didn’t listen to me and … that was great. I was so apologetic. And I said “that was not my intent at all. And I apologize.” And I thanked him. I said, I hope you can always feel you can let me know. I said, I don’t know if I was distracted, but I apologize. Let’s revisit it or let me try to hear you better. You know, and I for example, I had a transgender patient. And I was pretty consistent and calling them by their preferred name. But then one time, I got it wrong. And they said, “just a quick reminder, I’m not upset. But I just please, if you could really call me by what I prefer.” I said, Oh, I’m so sorry. You know, I do try, and I wasn’t upset, to be reminded.  Don’t assume that people take offense, don’t assume that your doctor or nurse can’t receive feedback and improve because we want to do a good job. Maybe you thought they were recoiling, because you were talking about whatever you’re talking about. Maybe you misread them,…

AW: Right. Maybe they had a stomach ache!

JT: Maybe … maybe their phone was going off and they were distracted or responding to their buzzing phone in their pocket, right. And you thought they were responding to you. So before you change providers, give them a chance to do better, and explain what better looks like for you.

AW: Again, I think people are going to be lined-up to be one of your patients. Is there anything else? Is there anything else you want to add in terms of advice to people who are looking to optimize their communication with their doctor?

JT: Just to, really see it as communication. You know, obviously we do tests and we do physical exams and stuff. Most of the value is coming from the communication. And so yeah, I’ll do a physical exam. And yes, I might order an X ray or some blood work or whatever. But most of what I need is coming from the communication. And most of what you’re going to need to get out of this is coming from the communication. And so again, as we’ve been talking about, the more we can structure the communication part to be as successful as possible is really the key.

AW: That really speaks to the significance of this topic, right?

JT: Absolutely, yeah.

AW: When I, when I was thinking about this topic, I said, this can really help people, it’ll help people hopefully disarm them from any embarrassment they have, but also give them strategies. So that next time they go to their doctor, they feel more in control, but they’re also just improving the quality of the communication and therefore the care that they’re receiving.

JT: You know, as I’ve gotten older and more experienced, obviously, I still do lots of physical exams, but it has become a smaller part of how I use that 20 minutes or 15 minutes or whatever. Because I’m really appreciating that so much of the nuance and so much the what I actually need is coming from the communication, and not just the laying on of hands, there’s still the laying on of hands. But it’s really the communication that allows that laying on of hands to be much more focused and much more, extracting more relevant information.

AW: Interesting. Okay. Let’s move on to the five Rapid-Fire questions.

JT: I was nervous about this.

AW: You shouldn’t be nervous!  That’s funny. First question, what are your pet peeves?

JT: So I think we share one. This one, which is clutter… I do tend to like some white space. And I’ve talked a lot about this with my spouse, who perhaps has a different view on this. I think our lives are so full and so intense with information and with activity and with so much, that the more there’s this sort of additional visual noise, or where it’s hard to find things as easily. And it hasn’t always been that way. But I think as I’ve gotten older and as you know, in our mid-life, and things are so full with young kids and a busy clinical practice and administrative practice. There’s so much to do that just the shoes in the middle of the hallway, the bags casually thrown down in the middle of the hallway, papers strewn over the dining room table. It just, it just feels like it just adds up.

AW: I agree. And I think when you believe it, it becomes even more true.

JT: Right.

AW: You know what I mean?

JT: Absolutely. And so I did actually read, the night before I started in this new job, that Maria Kondo book.

AW: Tidying up?

JT: The tidying up book. And it really resonated. it’s a funny story. So I was nervous. I was a first-time hospital CEO, and I was nervous. And so I couldn’t sleep. So I went on the library, I downloaded an audio book. And it was this book, and I thought, This is great. So I got up in the middle of the night, like one in the morning, and I spent like three or four hours, doing the first two chapters of the book. My wife woke up, and there’s bags of all my clean stuff. But I must say, my drawers have not reverted back. I didn’t get through all the chapters in the whole house. But when I open the closets in the morning, when I come home at night, whenever, it just feels a little bit easier.

AW: So Gretchen Rubin, who originally was studying happiness, recently published a book called Outer Order, Inner Calm, but I feel like you could write the book.

JT: I don’t know. I think I’m a fan of it.

AW: Okay, question number two, what type of learner are you?

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