Dr. Weisman: Hey fellow fierce physician females, it's me, Dr. Errin Weisman, your colleague in medicine and coach in life and this is Doctor Me First, a podcast all about authentic conversations between us, female physicians, to bring encouragement, community, hope and fun to your life and your practice.

Dr. Weisman: Today's episode is episode number nine, and I am talking with Dr. Irene Tien. The word that she chose is hilarious because we all have it, it's frustration. So check our conversation out and stick around for a kick of encouragement afterwards.

Dr. Weisman: Hey everyone, I'm here today with Dr. Irene Tien. She is an emergency medicine trained physician at the University of Connecticut, and she is such an amazing person she went and got a fellowship in pediatrics emergency medicine. But the coolest thing about her is that she is involved with Telehealth, she blogs and she is a health literacy and patient advocate in the greater Boston area.

Dr. Weisman: She specifically helps guide patients in their health management. Whether it be from an injury or illness or help them to better understand their medical problems. I had invited my Linkedin community to join me on this podcast, and Dr. Tien was one of the first responders. So I'm so excited to welcome her today and have her join me on this podcast. So hey Dr. Tien.

Dr. Tien: Hi Dr. Weisman, thank you so much for having me.

Dr. Weisman: Yeah, we had chatted a little bit before this trying to figure out a topic, and it seems like maybe the one we ought to talk more about is frustration, how about you?

Dr. Tien: Yeah I don't think we'll have a problem talking about that and having enough material for that.

Dr. Weisman: Absolutely, so first I wanna hear more about what you're doing in telemedicine.

Dr. Tien: Okay, well I actually decided that I would be an entrepreneur and branch out from my standard emergency medicine practice, which I'd been doing for about 20 years, and branch out into telemedicine last September or October by joining a group called the Rowe Docs network, which is actually a group of multi-specialties physicians throughout the country as well as a few positions abroad.

Dr. Tien: We all provide telemedicine services for patients in an effort to increase access to doctors for patients. So I joined them because honestly I was frustrated, very apropos to our topic today, with my standard practice, so this was kind of a way for me to balance out my frustrations by taking control over my practice to some degree.

Dr. Weisman: That's amazing, well tell me a little bit more because I know my own frustrations with the current healthcare system, but tell me a little more about what yours are.

Dr. Tien: Well I find that as the years have gone on, that obviously our workload has increased steadily over the years, but I'm finding now that healthcare appears to be at a moment of ... we're on the precipice. We're at a moment of disruption, a moment of crisis, I feel like suddenly all the issues that had been simmering below the surface for the first 19 years of my practice are suddenly coming to the forefront, and things are changing at a speed I have never seen before and not in a good way unfortunately.

Dr. Tien: Some examples are declining reimbursements for the same or more work. Also, difficulty with ongoing and worsening drug shortages. Patients being told that if they are going to the ER and the insurance company takes a look at their visit later on that they could be denied coverage if the insurance company felt it was not an emergency.

Dr. Tien: So things like that are really very stressful for myself, but also for my patients. Despite the fact that everybody now is mandated to have insurance, unfortunately those costs out of pocket for patients is actually rising. So even though their insurance insured, the amount it's costing an individual family to be insured is rising, while the deductibles are also rising and the copays are also rising.

Dr. Tien: So in effect, you're asking the patient to pay much more than they used to pay for a lot less service. So all of these things together are really alarming me as a physician, and realizing now that these things are really affecting how well I can take care of my patients and how well patients can take care of themselves.

Dr. Weisman: Absolutely, I have those exact same frustrations. I had shared earlier that I was doing a cardiac workup on a woman who, when our pleasant registration person came in to tell them about some new insurance mandates on whether or not this visit would be considered emergent and covered, and I swear that it probably jumped up all of her vitals for the next five minutes. She was panicking, because she was having chest pain already, and then she was thinking about this not being covered.

Dr. Weisman: I just think as a physician we go into this career to help people so much, and yet I know on my day today, that I feel like all I do is rearrange the deck of cards.

Dr. Tien: Yes, I completely agree. I think that the problem is that we all, I shouldn't speak for everybody. I went into medicine because I wanted to take care of patients, and more and more I'm realizing that in order to take care of my patients, I need to do more than what I'm doing at the bedside. I need to understand the healthcare system, I need to understand why the healthcare system is the way it is in order for me to adjust my practice so I can take better care of patients, but also to help patients navigate the system so they can take better care of themselves.

Dr. Tien: But as you and I know, people who are holding the money are the ones who are making the rules and unfortunately that is neither myself nor the patient, and the rules are constantly being changed because the less that they have to pay, the better business for them. So it is almost a bit like a game, but I find that as a physician, I need to better understand the game so that I can better play the game on behalf of myself and the patient.

Dr. Weisman: I know because so many times don't you feel like when the rules change it's like playing chess, and then you're sitting down at a whole new board game from just yesterday even, trying to have to figure out ... I know that we talked about one of our frustrations too is, you know how doctors are being blamed for ordering too many tests.

Dr. Tien: Yes.

Dr. Weisman: We both practice in the emergency room, and people come to us for answers, we can't always give them to them, but I don't know about you, but I just get so frustrated. It's like on one side if I order this test, yes it's gonna cost my patient money, but if I don't order it, how much is it gonna hurt them if we don't find out what's going on with them.

Dr. Tien: Exactly, and I think the problem is that healthcare is a business now, and when you think about businesses, you think about well how am I going to spend less than I'm making. So if you're talking about fixing a car or going to buy groceries or building a house, those things of course you have to think about class and you have to think about benefits. But it's much more black and white if you wanna add on that third bedroom to your house, it's much different than trying to figure out do I need another component for this patient with CHF, completely different issues and to try to make medical care so black and white, like everybody fits in the same box for every different diagnosis is ludicrous.

Dr. Tien: But that's kind of how the business of healthcare is pushing us and consumers into a corner where they're expected to apply business principles to medicine, which they do not go together.

Dr. Weisman: I know that, and also working with students too. I mean they have such a hard time when we veer away from the algorithm, they're like what do you mean that we're gonna do this or ... I mean sometimes it's a good learning opportunity both for the student and for myself to have that conversation to understand why we are doing these things. But that's one of the biggest lessons that I try to teach coming through is that people don't follow the books.

Dr. Tien: Not at all.

Dr. Weisman: No, and that's the pressure [crosstalk 00:08:28] that we're under.

Dr. Tien: I think algorithms are a great starting place, and I think that consistency of care or our most common medical problem is great evidence based care of course, because none of us have time to read all of the literature and be 100% on top of every problem that we see in the emergency department, obviously.

Dr. Tien: But the problem I'm finding now with new trainees, is that they wanna invoke the algorithm, but they don't actually know what's in the algorithm or why the algorithm is the way it is. I think that's definitely a short fall that I'm seeing as a side effect of so many algorithms.

Dr. Weisman: Absolutely.

Dr. Tien: But definitely the experience that we get in training, the education that we get in medical school and residency. I mean really all of that is meant to allow us to think critically about the patient that we're seeing and I agree completely. Algorithms are great for guidance and a starting point, but not everybody fits in an algorithm, and that's where all of our thousands of hours of training comes in to try to sort out when should we divert from the algorithm.

Dr. Weisman: Tell me about your frustration, just to jump off of that when you have patients come with you who want a specific algorithm that they've found on the internet.

Dr. Tien: Right. Exactly. So I think the root of this problem is that there's a lot of distrust between patients and ... not between, but patients for their physicians. As an aside, I think one of the problems is that we are not good at PR as physicians. We go to work, we see patients all day, we go home, that's it. But unfortunately, the powers that be, we're trying to fill a deficit with the Affordable Care Act, costs need to be saved somewhere, and the places where most of the cost is spent in healthcare insurance and pharmaceutical companies, that is not where the cost savings are occurring because unfortunately for us, those groups have very strong lobbying powers and they understand the business of medicine better than we do.

Dr. Tien: So unfortunately those cost savings come down to us. So I think that when patients come in, they hear a lot on the outside about how doctors have balance billing that we're greedy, that we make so much money. They really, I think doubt where we're coming from when we're trying to take care of them and give them advice.

Dr. Tien: So I'd like to start those types of conversations with some sort of understanding where they're coming from. Then I find that explaining my thought process after having heard what they're in for as well as what research they've done ahead of time and explain myself clearly about why I agree or disagree. Hopefully creates a rapport where there's a lot more trust between myself and the patient.

Dr. Tien: So it is challenge. We are starting a bit behind the eight ball in this situation. But again, it does come down to a one-to-one patient to physician relationship, and at that basis of that person to person relationship, hopefully that's enough to get them on board to at least hear what I'm saying. I do find most of the time it does help, [inaudible 00:11:51]

Dr. Weisman: Do you find that in your telemedicine practice that you're more able to gain this rapport than maybe say like your Ed, is that what kind of attracted you to it? Dr. Tien: Well what originally attracted me to it was the entrepreneurial nature of this particular group, the Road Docs group, in the sense that I would have control over billing my own business and seeing patients the way that I wanted to see them.

Dr. Tien: But I think that the major advantage of telemedicine in the way that I'm practicing is that I have time to actually speak to the patient about their questions, their concerns. There's not as much interruption or rush like I experience in the emergency department. So almost guaranteed if it's a busy day, if I'm in a room with someone, it's very likely I'm gonna get interrupted.

Dr. Tien: When I'm in a telemedicine appointment, I have carved out a block of time for that one patient, and that allows me to give that patient my undivided attention, which is great. Then in my practice, what I love about it is that I follow up with my patients, which you know in the emergency department we really don't do that individually except in unusual circumstances. Although some people are sure excited about that than others.

Dr. Tien: But when you see 25 to 30 patients a day, you're not gonna be following up with 25 to 30 people the next day when you're back in the ER again. So with telemedicine, I do create a relationship that's a little bit different. So I do find that the relationship of [inaudible 00:13:21] plus they're choosing to see me versus ER, they're just choosing to go to the ER, they're not choosing me per se.

Dr. Weisman: Absolutely. I know one of the frustrations we had talked about too is the frustration on how doctors have lost the sense of control of their career and of their practice. Has telemedicine kind of reinstalled that feeling of control for you?

Dr. Tien: Yeah absolutely. I think that with telemedicine, because right now telemedicine services are not covered by insurance and have the freedom of basically billing the patient in a transparent way using no insurance. So kind of like a direct primary care model, where basically it's very clear on my website how much I charge and honestly, the charge is way lower than what you actually get charged when you go to an Urgent Care, because I actually did. My husband had to go to emergency care a few months ago, and the physician charge after insurance coverage was $200.

Dr. Tien: My charge to see you on telemedicine is $100. That's $100 I'm not gonna nickel and dime my patient every time I talk to them I'm not charging them, I'm charging them $100 to see them and any follow-up phone calls we have are part of that $100 charge. So really the goal is not to make bank on telemedicine. But the goal is to allow patients another opportunity to access a doctor more easily, while being able to actually make enough money to support myself and support the practice.

Dr. Tien: But this is where I've actually learned a lot about direct primary care, and I'm realizing now that that model is amazing. I'm amazed at what direct primary care doctors have been able to accomplish with regards to transparency and lowering costs for patients.

Dr. Weisman: Right, by just opening up services and just being innovative.

Dr. Tien: Absolutely.

Dr. Weisman: Being kind of swimming upstream ... I always explain to people, I'm like you know what, who I would really wanna be, Dr. Quinn, Medicine Woman. You get me on my horse, you get me my medicine bag, you pay in chicken and pie and we will be good.

Dr. Tien: I think a lot of doctors miss that time, if they remember it, miss that time where it was a bit on the simpler side and that even I would consider myself mid-career, 28 years in. But even in that period time, I've noticed a huge change in the way medicine is practiced. It's not unfortunately for the better. I'm seeing doctors leaving practice in droves, and it's just that they're all getting burned out.

Dr. Tien: I know there's a lot of chatter about whether burned out is really a proper term when it's not really the doctor that's the problem, it's the system. But you know everyone understands what it means to be burned out. It really saddens me to see wonderful clinicians leaving practice, not because they dislike medicine or they hate taking care of patients, but because the system is not allowing them the longevity in their career that they deserve and their patients deserve.

Dr. Weisman: Absolutely.

Dr. Tien: It's really a tragedy.

Dr. Weisman: And you know from my background that's a huge thing that I specialize on. I am only four years out of residency, and I can honestly say that I burned out. Either I was burning out in residency, or it was that first year of practice. That's what I explain to people so many times. This is not an individual's problem. This is a cultural issue, and the problem is, as physicians, we have let ourselves get so unhealthy on an individual basis we can't fight the cultural issue. We can't address the cultural issue 'cause we can't even be part of the conversation because we are so tired, fatigued, hopeless, that we can't even fight our own battles.

Dr. Weisman: I find that translates over to patient care too. When we see a physician who, there is, there just kind of that blank, crispy look about them. Their patient care does decline because they're in survival mode. I'm just so passionate about helping people get out of survival mode and get into thriving mode, and it sounds like you definitely have found a place where you thrive, and you have re-energized your passion for medicine with doing your telemedicine. That's amazing.

Dr. Tien: Well, I can tell you Errin that every six or seven years I find that I go through a mini-burn out. So even though you feel burned out and you're in the situation you're in now working in ER, you will find your energy again, and you'll go through several iterations of your career. Whatever you need to do to continue to do what you enjoy and find the joy back in medicine is worth doing.

Dr. Tien: Unfortunately, I think we do kind of get trained in residency and medical school to just put up and shut up. That unfortunately is the wrong lesson. If you wanna survive in the current healthcare system, physicians should stop putting up and shutting up because that is why we are here where we are with no voice.

Dr. Tien: So that's why I really jumped at the opportunity to be on this podcast with you because I think more physicians need to feel passionate enough about what they see going wrong with the healthcare system to actually say something and do something. Whether that's writing your legislator or educating your family or going out for advocacy and becoming an advocate for the AMA or your local medical chapter.

Dr. Tien: Whatever it is, it doesn't have to be huge, but educating yourself on why the healthcare system is the way it is and thinking about how you can contribute to the solution, does go a long way to help [inaudible 00:19:26]

Dr. Weisman: Absolutely, and you know the statistics say it's not if you're burned out, it when and the average number of burn-outs are somewhere between two and three for a career, so you're absolutely correct on that.

Dr. Tien: I'm almost done.

Dr. Weisman: You are almost done, yes, you are almost at your average and then you can just go smooth sailing. You know so many times they used to call it a mid-life crisis. But you know since it's gotten so much more significant, right now there's five key areas when burn out occurs. It's third year medical school, it's that first couple years of residency, it's fledgling physicians getting out mid-career and then that right before retirement. Physicians who are kind of at retirement age, don't wanna retire, but end up retiring because they are just done.

Dr. Weisman: So it's so key to identify that and like you said, I think that's where a lot of physicians feel stuck is because they're in a position that they feel like they can't reignite that passion for medicine.

Dr. Tien: Yeah, I think the problem is though a lot of physicians we're very isolationists. A lot of us practice, even though I practice in a group when I'm physically at work, I'm practicing by myself with a mid-level provider, and honestly I don't actually work with my colleagues.

Dr. Tien: I'm sure it's the same in family medicine. You're working side by side, but you're not working with each other. So we're all a bit isolationists in medicine, and I think we need to change that attitude and remember that we need to support each other if we want to support the profession.

Dr. Tien: I mean these days students are coming out with over half a million dollars in, I sorry, quarter million dollars in debt minimum. Much more than that usually.

Dr. Weisman: Absolutely.

Dr. Tien: And you've given up at least seven years of your life to train through medical school and residency. You're coming out in huge debt because you're basically working in residency at minimum wage. You've put off starting a family, you've put off everything in your life. You go out and start working, and you realize it feels like everybody's against you.

Dr. Tien: Not only that but god forbid you're one of those MDs or DOs who qualified for residency, but are one of those over 4,000 physicians out there right now who did not match. Not because they were bad candidates, because there weren't enough spaces because nobody wants to fund residency programs, but they do want to fund medical schools.

Dr. Tien: Why, cause in medical school you pay the medical school for your education, and when you leave they pay you to continue your education. So I think it's a tragedy that so many MDs and DOs out there are ... there's no pathway for them to practice or very few. Then once you don't match, it's like you're blackballed. Why don't we support each other. Physicians should be supporting each other. We should be supporting these people.

Dr. Tien: So I just feel like we're too isolationist. We need to start thinking of ourselves as a collective, and really, really go out of our way to support each other, not isolate each other. So another major problem I think [inaudible 00:22:35]

Dr. Weisman: I think so too is like you said the walls that we build. I hear that when you say isolationism. I love the work of Dr. Brene Brown, and she talks about vulnerability, and I know that that's kind of a hot topic right now is as physicians, how do we become vulnerable to colleagues. Because sometimes that is the support that we need, but it's the last place that we wanna gain support because we worry about how we look, our appearance. What is our name going to be if Dr. Weisman is caught balling in the supply closet because she just lost a patient.

Dr. Weisman: So I think it's really telling, setting up ... I know several hospital systems are starting to try to build back that community, and hence that's why I wanted to have these conversations. I want the doctor's lounge back. I want to have those talks. So I am just so glad to have you join me today. You are absolutely going to have to come back because we did not even get halfway through our frustrations list.

Dr. Tien: It would be my pleasure.

Dr. Weisman: Well great, we're gonna cut it off here today for today's episode. If you wanna find out more about Dr. Irene Tien, and what she's doing, please find her at her website at my-doctor-friend.com and I know that she'd be more than willing and happy to talk to any and everyone about the passion of her heart and what she is doing with medicine.

Dr. Weisman: So frustration, yeah, who hasn't been. I've gotta have a coming to Jesus meeting with you all and say, I have been totally frustrated trying to get this podcast going. Even just this first episode, trying to get all the technology together and figure out what I wanna say, and make it something cohesive. At one point, I think I was ready to throw the microphone and the computer up against the wall. Not gonna lie whatsoever.

Dr. Weisman: Now I look at it and it becomes perfectly clear, why do I let myself get so frustrated. Have you ever felt that way? In the moment you just, I get angry, that's my first thing to go to when I get frustrated. So that anger just boils up and then later on I look at it and think, gosh, why do I let myself get so emotional.

Dr. Weisman: I think that's a great lesson to take away from Dr. Tien's talk today with frustration. Is that the world around us is so chaotic, and there are so many factors that we just wish that we could control, we wish we could care for every patient, give them 110%, but the system just does not allow that or just other layers just do not allow us to take care of people how we really, truly want to.

Dr. Weisman: So in order to deal with that, we either have to change those factors, or we have to deal with how we internally handle the frustration. So one tool I wanna give you today, thinking about how you can handle your frustration is, doing my own damn advice to be perfectly honest. With the frustration that I've had with technology and having three kids and my husband working late and practicing medicine and everything coming together at once is that the first step is just to stop and be aware of the situation and name it.

Dr. Weisman: So just saying in the moment, I am so frustrated right now, and just giving it a name because I think so many times we just get a bubble up of emotions that it's almost overwhelming, and I know either I wanna get angry or I wanna shut down or I wanna run away from the situation. But when I stop and actually say what is going on with me at the time, it's almost like a cool breeze that kind of comes across my face and just helps me be like, okay, so that's what it is. So first step is awareness.

Dr. Weisman: The next step is assess, just like when we're assessing a patient. We're asking questions, we're doing a physical exam, we're looking through all their labs, getting a good picture of the situation that what's going on. So step number two is assess your situation. What is going in your life, what is causing that frustration. Is it something that's outside of the sphere of your control. Is it something that's happened, and then your mind is just going crazy, crazy, crazy with it, rolling it over, making it something maybe bigger or more deadly or dangerous than what it actually is. So stop and assess your situation, you're a great clinician, you know how to assess situations, you know how to assess people, and so just start asking those questions to yourself.

Dr. Weisman: Then the last step is action. So form just one small step of action that you can do to help with your frustration. For me, when I wanted to throw the microphone up against wall, I had to stop and my action was just walk away. Just walk away, it'll be there tomorrow, you can handle it then. It's time to get some sleep.

Dr. Weisman: Just walking away is an action step of its own. Maybe instead of letting it go and walk away, maybe there's an action step for you that feels better like saying, okay maybe I need to ask for help in this situation. Who can I ask. Or maybe an action step is to say, I am making this bigger in my head than what it is, lets really name what it is and deal with it from there.

Dr. Weisman: So the three steps again are, awareness, name what's happening. Assessment, talk and figure out walking through the situation what's really going on, and action, doing one small thing will be amazing to help you with what you're feeling at the time.

Dr. Weisman: Then from the next situation, the cycle starts all over again. Something new happened, you gotta gain new awareness, you gotta get more assessment, and you gotta have different action steps, and it's a perpetual cycle. Because guess what guys, life is not about the end destination, it is about the journey along the way. We are changing from day to day, week to week, month to month, year to year. You are not the same woman that you were when you started medical school.

Dr. Weisman: You're not the same one that graduated residency, you're not even the same one that you were last week. So it's okay to go through this process of change and making yourself better through it all. So I hope that helps a little bit with your frustration, and I just so appreciate you listening to this podcast.

Dr. Weisman: Well that's it for today's Doctor Me First. How are you gonna doctor yourself first through your frustration? I would love to hear if you have any suggestions that you do. So come visit me on Facebook with True Prescriptions with Dr. Errin Weisman and tell me how you're gonna deal with your own frustrations.

Dr. Weisman: Of course if you feel like you need to talk, if you are feeling burned out, if you just wanna sit down and have a chat with me, I would love to do this as well. I'm gonna put in the show notes the link to where you can schedule an absolutely free no commitments, no selling, no pushing colleague to colleague call, that I would love to hear from you.

Dr. Weisman: So as always, remember you are not alone, and your life, your calling, your pulse matters. Thanks.