Episode 11 - Humour and Boundaries in the Private PracticeJan 18, 2023
Dr. Kevin Mailo welcomes Dr. Bradley Block, otolaryngologist and host of the podcast ‘Physician’s Guide to Doctoring’ to the show for a discussion on using humour and setting boundaries in private practice. Dr. Block has a wealth of insight that he happily shares.
Dr. Block shares a rule he received from Scott Dikkers, founder of The Onion, on not punching down in using humour. The role of humour is to “comfort the afflicted and afflict the comfortable” and he shares examples of what that looks like in practice as a physician. Humour is a great way to increase rapport with patients and get them into a more relaxed state.
In this episode, Kevin Mailo and guest Brad Block talk about humour and how best to use it with patients, the flip side of how to carefully deliver bad news, why body language and non-verbal cues matter when interacting with patients, and how to draw important boundaries in private practice. While the instinct is to give everything to patients, a firm boundary for yourself and your self-care is vital to maintaining positive engagement with patients. This episode is both entertaining and enlightening.
About Dr. Bradley Block:
Bradley Block, MD, is a private practice otolaryngologist on Long Island, New York, where he lives with his wife and three young sons. He is a partner at ENT and Allergy Associates and creator of the Physician’s Guide to Doctoring Podcast.
He realized that rapport was the key to gaining trust, seeing patients efficiently, enjoying his practice, and building his reputation. He tried to find a podcast that would help him improve at doctor-patient communication, but there was none, so he created Physician’s Guide to Doctoring! The topics quickly expanded to “everything we should have been learning while we were memorizing Kreb’s Cycle,” and it is now a practical guide for practicing physicians, physicians-in-training and all allied health professionals. He is available as a keynote speaker on improving the patient experience, doctor-patient communication, and running office-hours efficiently.
Brad, or Dr. Block as his parents call him, went to med school at SUNY Buffalo and graduated with research honors. He then went on to his ENT residency at Georgetown. He enjoys spending time with his family, surfing (yes, there is surfing on Long Island), skiing (there is no skiing on Long Island), smoking meat, exercising, and finding any excuse to quote an 80s movie. “I’m not saying I’d build a summer home here, but the trees are actually quite lovely.”
Resources Discussed in this Episode:
- Scott Dikkers, The Onion
Dr. Kevin Mailo: [00:00:00] Hi, I'm Dr. Kevin Mailo and you're listening to the Physician Empowerment Podcast. At Physician Empowerment, we're focused on transforming the lives of Canadian physicians through education in finance, practice transformation, wellness and leadership. After you've listened to today's episode, I encourage you to visit us at PhysEmpowerment.ca - that's P H Y S Empowerment dot ca - To learn more about the many resources we have to help you make that change in your own life, practice and personal finances. Now on to today's episode.
Dr. Kevin Mailo: [00:00:34] Hi, I'm Dr. Kevin Mailo, the co founder and co host of the Physician Empowerment Podcast. And today I am very excited to be joined by Dr. Bradley Block, community based ENT physician down in New York and the founder of the Physicians Guide to Doctoring. And Brad, why don't you tell us a little bit about your practice background and what you're going to talk about today.
Dr. Bradley Block: [00:00:58] So I'm a general ENT and not realizing that going into general practice, private practice ENT would be mostly office hours. So, you know, in residency we're doing like four days a week in the operating room, half a day, maybe a full day of office hours, you know, and then lecture and the rest. In private practice, general ENT, we spend maybe four and a half days a week in the office and then another half day in the operating room, maybe a little more in the O.R. than that for some, but very, very office hours. And we see a lot of patients. And so what we're going to be talking about today is how I make sure that the patient experience is as positive as possible. Right? And so the reason that I founded my podcast, The Physician's Guide to Doctoring, is I noticed that there were a lot of experts out there that were helping people interact with other human beings, right? The interactions between salespeople and their customers, the interactions between people trying to date successfully or leaders and executives. But there weren't, there were these people with that expertise, but they weren't really focused on physicians. So I thought, you know what? I would love to hear what they had to say about specifically the physician-patient interaction. How do I get an audience with them? Well, start a podcast and then I can give them a call. And the physicians got to doctor and kind of sprouted from that because it became, really answers any questions that physicians might have that help us be better at physicianing. You know, it is either going to be the Physician's Guide to Doctoring or the Doctor's Guide to Physicianing. So better physicianing, whether it's in the office or interacting with our staff or being better community members, community leaders, public health issues, anything, anything that could help us be better doctors that we're not typically taught in our training.
Dr. Kevin Mailo: [00:02:55] Perfect. I love that. It is so true. I mean, this is the thing that we talk about at length here on the podcast. But in reality, during those training years, med school residency and those early practice years, we don't get a lot of training on that, right? And then the realities, as you alluded to, Brad, of going into practice and realizing that you don't have an hour for every single patient, right? So your patients need to feel valued, they need to feel heard, they need to feel that their concerns are important. And yet at the same time, you are running a practice where things have to move along, right? Because there are financial considerations to this. You know, you have to, you are a limited resource as a physician. We all are. And so how do we serve our community? How do we serve our patients as a whole? By being efficient, yet at the same time maintain that human connection, which I think is so, so important. So take us through. Take us through your approach. What have you learned? Maybe even share some failures or struggles. Tell us a little bit of wisdom, Brad.
Dr. Bradley Block: [00:03:58] So one of my favorite guests was Scott Dikkers, who founded The Onion. And I had him on on How to Be Funny. And he wrote a book called How to Be Funny, How to Be Funnier, and the finale to the trilogy, How to Be Funniest. And so he had a great rule for physicians and really for anybody, essentially don't punch down. But what it comes down to is the role of humor is to comfort the afflicted and afflict the comfortable. And so when you're deciding whether or not you want to make a joke, because if you joke around with your patients in the office, that is a great way to connect with them further, right? It's a great way to establish more rapport, to establish trust. People learn better when they're in a more relaxed state. And so you're going to decrease that cortisol that's coursing through their blood vessels when they're in the visit. So it helps them retain what you've what you're talking to them about and understand better. So there's a lot of roles for humor in the in the exam room. And so you always have to make sure you're using it to afflict the comfortable and comfort the afflicted. And so the afflicted in this case is your patient, right? And so you never want to make fun of the patient at all by any means. And then so who can you make fun of? Really, anyone. As long as you're punching up. Like you can make fun of the disease, you can make fun of the electronic medical record, you can make fun of yourself, although you have to be careful because you don't want to use humor that makes you look less competent at what you're doing. So you don't want to look like you're using like slapstick humor to look like you're bumbling. You can make fun of the institution. So there are lots of things that you can make fun of. And you said, look, one of my failures. So how do you recover from a failed joke? That's easy. You can use the same joke every time because even though it's the same thing to you, each encounter is a different patient. So you could always say, Oh, all right, I got it. That wasn't funny. I'll stick to doctoring. I won't, I won't make my foray into stand up anytime soon. So, you know, it's a quick and easy way to recover from a joke, but just identify that you made a bad joke because that can really sour the relationship.
Dr. Kevin Mailo: [00:06:09] Excellent. Talk to us about not using humor. Talk to us about bad news.
Dr. Bradley Block: [00:06:16] Bad news. Okay. So. So a great way... so you have to have a system when you're breaking bad news. You can't go in there without having a plan, just like when you're doing a surgery. You have a plan going into the operating room, right? If you're doing a procedure. When you're breaking bad news, you need to think first about how you're going to break the bad news. And a lot of times what you can do is you go through the steps with the patient of what's gotten you to this point. And what that helps them do is that helps kind of soften the blow as you're getting the bad news, as they're getting the bad news, because they can tell what's going on. So do you remember you came to me with that bump on your neck, right? And we weren't sure what it was. You'd already treated it with antibiotics. It wasn't going down. And so we decided to image it with an ultrasound. And that ultrasound, it really didn't come back with anything specific. So we decided to do a needle biopsy. Right? And what were we, you know, we were worried about that needle biopsy with was the possibility of cancer. Well, we got the results back, and unfortunately, that is the result, that it was cancer. And it's always important to use those words. Right? You don't want to say tumor, you don't want to say mass, you don't want to say malignancy, like use the C-word. Use the, you want to be frank about it. So you can kind of ease them into it that way. And once they have the news, you have to give them a chance to process it, right? So just let them, give them some time to sit with it. You can even give them some time to talk to someone. Would you like to call a family member right now? Would you like to... Listen, you have as much time as you need. Call one of your family members. Talk to them about it. I'll be back in a few minutes. And when you guys come up with some questions, we'll go over them. And then another thing they're going to need is they're going to need a clear delineation of next steps. And oftentimes, we don't have all of the steps, but they need to know what's happening next and it needs to be given to them with a good amount of confidence. Now we're talking about confidence. This is where we get into non-verbal communication. And so non-verbal communication can really be broken down into two different types, right? You want to convey interest and authority.
Dr. Bradley Block: [00:08:45] So when you're conveying interest, that's more like facial expressions and body language. I really love the term body language, but helps people to understand what's being said. So you convey interest, you know, keep eye contact, make sure you're actually emoting with your face. Right? Some of us get kind of stone faced, so you're emoting with your face and then the cadence and the volume of your voice can convey that authority. So when you're conveying that information, you want to convey it with that authority. So you're giving the bad news. You're emoting with the patient, right? And you are demonstrating that you have authority over what's going on with them. Like you're demonstrating your expertise. So. And then you need, that's when you come up with the plan. You don't want to go too many steps ahead as much as they will want you to. But what you do is you give them a clear follow up. So the next step, we're going to order this imaging. In m field, it would probably be okay, we're going to get a CAT scan to the head and neck with contrast, we're going to get a PET scan, and then you're going to follow up with me two weeks later. I want you to write down all of the questions that come up. I'm not going to have many answers now, but I'll answer what I can. But as you're processing this, you're going to come up with a lot of questions. Make sure you write them down, because each visit is going to be a lot more information than the last one. You might forget the questions that you have, so make sure you write them down and make sure you come with somebody. You don't want to come by yourself to these visits because of the volume and the complexity of the information that you're going to be getting. The reason I'm using cancer is the example just because in my field, that's usually what ends up being the bad news, and it's common in other fields as well. So those are a few bits of advice for how you break the bad news and how you kind of walk them through what's going to be happening next because they're going to feel like they've been cast out into space with no gravitational pull to bring them back and they don't know what's going, what side's up and what's down. So you give them some touch points to hold on to, and then you go from there.
Dr. Kevin Mailo: [00:11:01] So, many of our listeners are family physicians in private practice. And again, one of the big things that we feel is that time pressure and one of the commonest things - you probably don't get it as much as the specialist, but we get it all the time in family medicine - is that And what about this? And what about this? Right? And as patients struggle to access primary care, they often will come in with a laundry list of complaints or issues that they want worked out in that 50 minute appointment. And I completely sympathize with those patients. I do the same thing when I go see my own family doctor. So what do you do when you're having one of those days and you are running behind and not like 5 minutes, you're an hour behind because maybe it was a couple of difficult conversations around cancer. Maybe there's a whole bunch of loose ends. Maybe something blew up at the hospital or the O.R. and you're late getting into clinic, whatever. How do you navigate that data? How do you keep your composure? How do you make your patients feel valued? How do you speak to them honestly about what's going on, when, you know, for many patients, it's not easy, right? People got child care to coordinate. They got careers. You know, some people take a bus to get to the other side of town and see you. Tell me what that looks like.
Dr. Bradley Block: [00:12:13] So as an otolaryngologist, this happens as well.
Dr. Kevin Mailo: [00:12:15] Okay.
Dr. Bradley Block: [00:12:16] You know, I've got a patient that comes in with an active nosebleed and they also want to talk about their CPAP machine. Oh, and also they've been having some dizziness lately, probably because they've lost a bunch of blood from the nosebleed. But, you know, they assume that it's something from their inner ear. Everyone assumes it's coming from the inner ear. I can't tell you how many people I see when it's like, Oh, yeah, it's my earwax that's causing my dizziness. Okay, so just for the audience, earwax doesn't cause dizziness, okay? It's a skin issue. Can cause hearing loss. But okay, so it's important to create boundaries. Now, I recognize that you said some of these patients are coming, they took three busses to get there, but you still have to create those boundaries. And I've gotten better at it as I've gotten along in my practice. Like I used to have patients, like they come in and they can't hear anything. Why? Because they have bilateral middle ear effusions. I could do a myringotomy at the time, but like you said, I've already got four patients waiting. So you know what? That procedure is going to have to wait. They're going to have to reschedule, make an appointment, and we can do bilateral myringotomy, maybe with tubes, we'll see. So I've gotten, I've gotten better about that. But yeah, that happens to me. I would make, when they come in, right, if they come in with that list at the get go, give them the choice of what they want to talk about. Okay. You get to pick two things and I get to pick one thing, but we're only going to talk about three things today. Or vice versa. I get to pick one. I get to pick two. You get to pick one. So whatever you feel comfortable doing as the physician. But they don't get an infinite list of things to discuss. And if you're already out the door and they say, Oh, wait a second, I also want to talk about this, Great, I'd love to talk to you about that. Unfortunately, we've run out of time. I do have three other patients waiting. We've covered a lot today. We talked about X, we talked about Y, we talked about Z. But we don't have time to talk about that too. So just schedule your follow up. It sounds like an issue that you should probably discuss within 3 to 4 weeks or whatever timeline you decide. But it's important to draw those boundaries. And as physicians, we're not trained to. We're trained to give up everything. Stay late, like miss your kid's birthday. I got a patient they wanted to be squeezed in today. It was my kid's birthday today, right? I'm already in the, you know, I'm already getting home late enough.
Dr. Kevin Mailo: [00:14:29] Exactly.
Dr. Bradley Block: [00:14:30] Like, no, no. Like, you can see one of my partners, or I can see you within the next couple of days. But no, I'm sorry. I just. So you have to get better at drawing boundaries. And you do that by keeping the patients to just a couple of issues.
Dr. Kevin Mailo: [00:14:44] You know, one of the things that I found helpful in the emergency department in my own practice is very often I'll take, I'll sit down with patients and I'm later then I said I would because inevitably I get called away to an emergency, something more urgent in the department, I get interrupted to deal with a result or something like that. I come back, I sit down with my patient, I apologize that I'm late, but I say this is important for me that I give you time and it's important for you that you get time. So now I've created time for you because I'm now towards the end of my shift. Let's say if it's something serious or complex, like a geriatric patient, there are a whole bunch of issues. I want to sit down and make sure that I am not rushing that. And as you alluded to earlier, Brad, that body language is everything. I make every effort to sit at eye level or lower than my patients and be near with them and never look like I'm in a rush when the department is busy. I really try to create that space in that time. And that's even about setting boundaries with other patients or residents or whoever wants your time. Right? And just saying, I have to go in here for a couple of minutes and sit down and talk to a patient, really convey or go over the issues. So I think that thing about boundaries is so important. And in terms of our self care, we do a better job when we're caring for ourselves, right? If you were running late today for your child's birthday, seeing that patient, I mean, how good is that patient interaction going to be? Right? Because there's probably going to be some degree of frustration or angst or worry that carries in your voice as you interact with your patient versus any other day, Brad, when you could have sat down and created that space for them. So I think it was such a powerful observation that you made in terms of setting those boundaries.
Dr. Bradley Block: [00:16:30] Yeah, the non-verbal cues, they can pick up on that, they can pick up when they know that you're rushed. But it's also important that you convey those non-verbal cues. So sometimes, as I said earlier, we're a little stone faced, myself in particular, and they have trouble reading that we're interested. So it's, you can't fake it, but you can make sure that you're conveying it. And that helps those visits to actually go, those other visits to go faster. And when they feel like they're being heard, they feel like they're being understood, that you're more likely to move through the visit faster than if they're getting frustrated because they don't feel like they have your full attention. And that's often why they need to repeat themselves over and over. Another reason why they end up repeating themselves is because there's something that they're not saying that you need to get them to say. And sometimes it's important to really pull that out of them. And like, and I find it a good way to do that is say, What's bothering you about this? Like, right, people come to see me with with globus, right? They feel like they've got something stuck in ther, there's nothing actually stuck in their throat. What are you, what bothers you about this? Do you, do you think you might have cancer?
Dr. Kevin Mailo: [00:17:41] Right?
Dr. Bradley Block: [00:17:42] Yes, I do. Well I'm going to do this exam. And by putting this camera down your throat, I'm going to be able to see whether or not there's cancer. And if I can't see anything like it's extraordinarily unlikely that there's anything there. Right? So getting them to verbalize what's bothering them about their particular symptom can often get you over that hump where it seems like you're just going in circles, you're saying the same thing, they're saying the same thing. So a good question like that can move things along nicely and then everyone leaves the visit feeling more satisfied.
Dr. Kevin Mailo: [00:18:12] Yeah. Boy, I love that. So, Brad, this was absolutely outstanding. I don't want, I mean, I think we can go on and on and on. But give us give us your wisdom. Give us your insights. We have a lot of young listeners who are here. And I think even for for those of us that have been practiced for years, this is the one part of the job that we continue to evolve on. I continue to be humbled throughout my career by the things that patients have shared with me that were unexpected, that if I just took time and listened, I really came to appreciate the patient's perspective. So share share that wisdom with us, share your insights on how we can keep that humanity in medicine that's so important not only for our patients, but for ourselves as well. Because medicine is not a business. Medicine is not a technical skill or a set of knowledge. It really is a human, a human career.
Dr. Bradley Block: [00:19:05] Really, it goes back to what you said, right, about making sure you're taking care of yourself. Because if you are hating life, you're going to resent your patients for it, right? If you're burning out, you're going to resent your patients, and that's going to put up those boundaries, it's going to take away from their care. And it's not their fault that you've made these decisions or the system has put these these things upon you so that you can't take care of yourself. So you really, it's really important for that self care. And it's not just lip service, right? Like we've all been in that, I've been in that place where I've resented, I've resented it, I've resented the patients because I've burned myself out. And that's where the boundaries come in, wherever you decide to put them, wherever you decide it works for you that you can really enjoy. And I'm in that place again. I'm in that place again where I'm really enjoying what I'm doing. I mean, I do plan on retiring at some point. I'm not going to do this for, I'm not going to, you know, I'm not going to be those people that's like, oh, it's my passion. I enjoy it, right? But I definitely enjoy it. It's, I'm not in that bad place anymore because I figured out how to make those boundaries. So self care boundaries, all that, all that stuff, wellness stuff that we say, it really does make sense. It's just every person has a different way they need to go about doing it. You got to figure out what works for you and that might evolve as you practice. But yeah, you've got to look out for number one first.
Dr. Kevin Mailo: [00:20:33] Well, I absolutely love that. So again, for our listeners, I'd encourage you to track down Brad's podcast, The Physician's Guide to Doctoring, and he has got so much great material, so many great episodes with amazing guest speakers. So I'm very honored to have had you today, Brad, joining us on the Physician Empowerment Podcast. And for anyone listening, if you want to be a guest, we're always looking to hear from members of our profession and hear their perspectives and hear what they've got to share. So again, thank you, Brad. Absolutely loved it.
Dr. Bradley Block: [00:21:06] Thank you, Kevin. It's been a lot of fun.
Dr. Kevin Mailo: [00:21:09] Thank you so much for listening to the Physician Empowerment Podcast. If you're ready to take those next steps in transforming your practice, finances or personal well-being, then come and join us at PhysEmpowerment.ca - P H Y S Empowerment dot ca - to learn more about how we can help. If today's episode resonated with you, I'd really appreciate it if you would share our podcast with a colleague or friend and head over to Apple Podcasts to give us a five star rating and review. If you've got feedback, questions, or suggestions for future episode topics, we'd love to hear from you. If you want to join us and be interviewed and share some of your story, we'd absolutely love that as well. Please send me an email at [email protected] Thank you again for listening. Bye.