EP131: Beyond Diagnosis: Enhancing Doctor-Patient Bonds with Dr. Eric Fethke

This episode of SEE HEAR FEEL is an edited version of an episode from the podcast, The Pursuit of Health with Dr. Eric Fethke. Dr. Fethke and I talk about my journey in healthcare, professionally and personally. The discussion emphasizes the importance of improving doctor-patient connections through empathy and psychological understanding. Key topics include the impact of emotional perceptions in medical interactions, the role of metacognition in healthcare, and practical strategies for physicians to foster meaningful relationships with patients. We highlight the need for incorporating these concepts into medical education to enhance overall healthcare efficacy.

00:00 Introduction

00:49 Personal Experiences and Realizations

02:30 Challenges in Doctor-Patient Relationships

03:49 Emotional Perception and Patient Advocacy

09:19 Metacognition and Its Importance

11:59 Implementing Metacognition in Medical Practice

14:26 The Pursuit of Health and Relationships

Transcript

Eric Fethke: [00:00:00] Welcome back everyone to the Pursuit of Health podcast. I'm your host, Dr. Eric Fethke. On this episode, I'm excited to have a special guest, Dr. Christine Ko, join us. Dr. Ko is a Professor of Dermatology and Pathology at Yale University, where she's made significant contributions to our understanding of skin disease. Dr. Ko's impressive credentials include several academic books published on dermatology, a children's book about deafness inspired by her own son's experience, and as is the focus of our conversation today, she is the author of How to Improve Doctor Patient Connection, Using Psychology to Optimize Healthcare Interactions.

Dr. Ko's work blends professional expertise with personal insight, aiming to bridge the gap between healthcare providers and patients for more effective and empathetic healthcare. On today's episode, Dr. Ko discusses how she came to understand that our patient physician relationships were in need of improvement.

Why do you think it's important as a dermatologist [00:01:00] and a physician to look below the skin and really look at the whole person? 

Christine Ko: Great question. My son was a patient, so I was a patient advocate for him. Many medical encounters that we had were very much focused on a objective. So for example, my son is deaf and has cochlear implants. And so it would be: do the audiology testing, do the hearing testing, and that would be it. There would be hardly any explanation of what the results were, or could be, or what they would mean. There was never any time. And even if I would ask what does this mean? You could tell everyone's rushed. And there wasn't enough time, really, for answers.

And in all honesty, I realized that I was treating my own patients the same way. Not that I was consciously thinking, let me be very brief, short, with this patient. I reflected on myself, what [00:02:00] am I doing? If I don't think I'm doing this intentionally to my patients, what's going on? Everything in my training was all about, what's the problem? That is not bad, right? As a mother of a patient, yes, I want the problem solved. And so That is hugely important, but how to balance solving the problem but also seeing the patient and seeing that the patient is not just that one problem or several problems.

Eric Fethke: I've been a doctor for decades, and my patients often express to me that they expect mainly technical. You've touched on this, but You've touched on this, but no significant personal interaction with their doctors. Their expectations seem really low. How did we get here? 

Christine Ko: I think What's being forgotten in the doctor patient relationship is that this is still an interaction between two people. It's not actually about solving a problem or the financial bottom line. I think that we've gotten here [00:03:00] because we are used to interacting with people and we pick up on clues, and patients can tell right away when the doctor walks into the room, when I walk into the room, whether I'm really there, or not. And so it starts from really second one. Just as if you're having a slightly awkward conversation with an acquaintance, and you realize within two seconds, maybe, Oh, this isn't quite going the way I want. We know this in life, that there are ways to try to fix it. But I think in that patient interaction or the clinic, we don't do it. Not only is it because the doctors are busy; the patients might be busy as well. And from the get go, the doctor rushes in and the patient realizes, okay, this doctor isn't really here. And the patient maybe doesn't try to do anything about it. But I think also it's sometimes because, and this is the emotional perception piece. As the patient advocate for my son, sometimes I was very anxious and fearful. Emotions, especially a [00:04:00] stressful emotion like that, it does affect how I act for sure. And the doctor is rushing in and I realized, okay, this person maybe doesn't have time for me today, but I need this person to have time for me. It wasn't necessarily easy for me to say, Hi, Dr. Smith, so good to see you! With a big smile and a light tone. Sometimes that is not possible for patients and their family members, as I'm sure you've seen in pediatric cardiology where the problems sometimes are huge, right? It's a problem potentially of life or death. Or shortened life versus longer life, and that's stressful. How can the system expect us to walk out of there, easily? But actually, a certain number, like five, concepts in cognitive psychology that have come out in the last 20 years, which is like post my medical training and everything, can really make a difference. And it's really changed quite a bit [00:05:00] how I doctor, and I think it's made me a better healer. It's really been important for me. 

Eric Fethke: Do you think that we as physicians, importantly, have we been ignoring our own gut? The thing that tells us something's wrong here. This isn't working. This isn't how I thought medicine would be. 

Christine Ko: Yes, so doctors are really busy. I don't know any doctor who's not super busy, including me. People in general are very busy. And so I think what happens is, busy is stress, right? To me, busy equals stress, and stress isn't necessarily bad. But I think the busier we are, or the more stressed we are, we're looking for easy solutions, right? So how can I lessen the stress as quickly as possible? It's a normal human reaction. That's also, I think, instinct, like, I want to get out of this as quickly as possible. And you default then to what's easy for you, and highly trained doctors, what's much easier, at least definitely for [00:06:00] me; easier is if I walk into the room, I'll just be perfectly honest. If I walk into a room and a patient is upset, and I know I'm running behind. My instinct is, let me get out of this room as quickly as possible by solving this patient's problem. That, in all honesty, is my gut instinct and feeling. But wait a second. If I actually spend 20 seconds and say, Look, I'm really sorry. I'm running behind. I'm sorry to take your time that way. I'm also feeling stressed about this. And if I say something like that, the patient immediately is, Oh, doctor, I know you're busy. It's fine. And just with that five, 10 seconds of explanation, like, we both feel better. In any relationship, if someone's been waiting for you at a cafe for an hour, and you come in and you give them no explanation, we wouldn't do that in normal interactions. In the past, when I haven't done that, why didn't I do that? I [00:07:00] think it was like, honestly, admitting to not doing things perfectly. It was obvious that I'm not doing it perfectly, but for whatever reason, I think like a little kid right? who's two and is trying to hide that they like ate the candy when they shouldn't have? I didn't want to admit that I'm failing, I'm running an hour behind. It just goes back to, I expect myself to be perfect. And so I think for me, one of the biggest hurdles in this journey of mine has been to recognize how human I am, which sounds dumb, right? Did I not think that I was human all along? 

Eric Fethke: The patient, ultimately, is saying, I've seen this in their eyes. They're saying, Catch me, I'm falling. And if you drop them, you literally psychologically drop them, they land on the floor. And if this has happened so much, they adapt and they learn not to expect anything different from us. 

Christine Ko: Absolutely. 

Eric Fethke: And so ultimately they expect a very superficial interaction. There's no bond there, [00:08:00] and they don't expect one. Nobody's catching each other, and that's ultimately very dangerous.

Christine Ko: Yes. I give a little anecdote about that in my book. The surgeon who ended up doing my son's surgery, the cochlear implant surgery, his name's Dr. Roland, he's at NYU. 

Eric Fethke: Beautiful words. Yes. Please share that with us. 

Christine Ko: He said to me, Let us help you carry this burden. And, I was floored when he said that. I was flooded with such a sense of just, wow, they're going to help me carry this burden. 

Eric Fethke: Did you expect him to say that? 

Christine Ko: I didn't expect him to say that.

Eric Fethke: You've touched on the fact that the education system itself or the way we do things is not teaching us this. That's why your book, as many of your reviewers have said, should actually be part of our education. One of the problems is that there's no uniform way of teaching us how to approach these issues. You've turned around and said, [00:09:00] Metacognition, here's the solution. The doctor should say, who is this patient in his or her own eyes? And the patient says, can the doctor actually see who I am? I thought that was a wonderful metacognition exercise to do, right as you walk in the room. Ask yourself those two sets of questions. Tell us why you chose metacognition as the solution.

Christine Ko: It's just taking a moment to reflect. We'll have a gut reaction, all the time. Cause that's how we go through life. So that's normal. I've tried to not judge myself for my first reaction. Most of my time in practice as a doctor, my initial instinct, my initial thought process has just been, what problem is here? And not, as you were just saying, who is in this room?  By ignoring the human aspects, somehow we think we're being more efficient, but I think just a tiny bit of attention to the human aspects actually makes me more [00:10:00] efficient. That's where that metacognition piece comes in because it's just really thinking more than once, sometimes three times, five times, what is really going on here? What does this patient really need based on who they are? I think it's very important. 

Eric Fethke: As a clinician, what are the conscious thoughts we should be doing as we go through using metacognition? Give us a couple of examples, because your book is full of them, but like a starter, a teaser, how do we do that? 

Christine Ko: Being able to admit to error. Recognize that we all fail, and that's part of being human. The psychological concept is the growth mindset. Carol Dweck's concept. She's a psychologist at Stanford. She has an article where it says, it's a very fixed mindset in medicine. That idea of being 100 percent perfect all the time, that actually is a fixed mindset. A growth mindset on the other hand means, okay, I might be aiming for 100 percent perfect, but I recognize that along the ways there [00:11:00] has to be these valleys of failure on the way. And I accept that. And the next piece to that is deliberate practice. So that's Anders Ericsson, another psychologist. His big concept was deliberate practice. So we call seeing patients practice; like in my practice, this and my practice, that. So we say we're practicing, but we're just focused on the medical piece, right? I'm practicing making the best diagnosis, the most accurate, getting the best cure. To me, sort of a revolution in my own mind was, okay, there's also a practice of really seeing the patient for who they are, the entire patient, and how do I practice that? And so the deliberate practice of that was eye color. Did I recognize their eye color? For you, you started practicing, what are your goals? 

Eric Fethke: Your metacognition approach is so helpful because how we think, understanding what the patients may be feeling and thinking; the visual cues, the auditory cues, the feeling cues: it's really a whole science of its own. Do [00:12:00] you think that this is something that we have to bring into the medical education? 

Christine Ko: Absolutely. It could be an online course, right? Medical school is packed. I don't think it's necessary to spend three months on metacognition because it ends up, you have to practice this stuff. Once you start seeing patients, you practice this stuff. So I think just as long as people are aware how much breadth and depth there is to cognitive psychology. It just takes a little bit of awareness and reflection. And so in some ways I don't think it actually has to be a course, per se. Even if a medical school said, look, there's this podcast or there's this online video that's 30 minutes long or an hour long, watch it, and just think about it. And if just every once in a while, in every rotation or every year of medical school, if they touched on it, it would show that this is something important. Whereas right now, I think a lot of medical schools have courses on doctor patient examination, or the doctor [00:13:00] patient exam and questions, or history taking; they have that, but they don't really necessarily address, say, for example, the emotional piece, right? And it would just be simple to say, okay, and also think about the patient's emotions, and also think about your own, and how they play off of each other. They will play off of each other. 

Eric Fethke: Many of the things that we practice today or we do today, we think are so brilliant, we don't realize how long it took to get into the bloodstream, so to speak, and become part of our culture. I think you're absolutely right. I see in the best athletes, Michael Phelps and people like that, they'll go back, and they'll watch their races over and over again and analyze, what did I do right? What did I do wrong? How can I make it better? That mindset, you're absolutely right. That's how it has to be. That's the metacognition. They're doing it in real time to make themselves better and better. Ultimately, that's what we all need to do as physicians. Stepping back and looking at ourselves, what did we do right? And what did we do [00:14:00] wrong? I agree if we're teaching how to do a physical exam from head to toe, if we're teaching how to write a note, why isn't metacognition taught as the third component, the triumvirate of, from here on out, this is how you're going to do it. Let's talk about the metacognition piece. Is that done right? Let's practice that. And, you don't have to have a course about it separate. It needs to be ingrained in how we do care.

Christine Ko: Absolutely. Totally agree. 

Eric Fethke: And on that last component, what do you think the pursuit of health is? For you as a dermatologist, a clinician, a well trained clinician today, as a parent, as a patient, as somebody advocating metacognition, improving the patient physician connection, what's the pursuit of health for you?

Christine Ko: It's about relationships, right? I think that's what life is about. It sounds trite, but I think it's true. Good relationships with individual patients, right? Also good relationships with my kids, my husband, [00:15:00] with my friends, with my family, my parents, my sibling, all of that. That is what the pursuit of health means to me as a physician then, how do I help this person have great relationships with the people in their life, right? To have those kinds of interactions in daily life, and in medical practice, where we're really trying to see each other fully, I think that's really what the true pursuit of health is.

Eric Fethke: It's a beautiful idea. The relationship with yourself, the person themselves, who they see themselves as, that's a relationship. The relationship of the doctor. How do I see my role here? The relationship between the two of us, the relationship with their family, with their community, nation. Ultimately, the health of a nation depends on how we see each other in relationship to ourselves and to each other. Who are we amongst each other? It's a beautiful [00:16:00] and important point here. It puts metacognition in the context of relationships. Metacognition not as a objective of its own but a tool to get to those meaningful relationships that we all seek in our lives. We've assumed, we've taken for granted, that this happens, and it's not. It's something that we have to practice, how to improve doctor patient connections, using psychology to optimize healthcare interactions, so ultimately we have better relationships.