Latest / Voices of Otolaryngology / Beyond Listening: Bringing the Patient Voice Into Care

Transcript

Beyond Listening: Bringing the Patient Voice Into Care · Voices of Otolaryngology

• 0:01
  Welcome to the voices of Otolaryngology.
• 0:03
  I'm your host, Rahul Shah, CEO
• 0:06
  of the American Academy of Otolaryngology Head/ Neck Surgery.
• 0:10
  Each episode, I bring people from our specialty together
• 0:13
  to talk about the work, the questions and the ideas that move us forward.
• 0:17
  Let's get into it.
• 0:20
  let's dive right in.
• 0:22
  I'm here today with Doctor Emily Boss from Johns Hopkins University.
• 0:26
  And I really want to know, Emily, how did you find the patient's voice?
• 0:31
  Well, thanks for asking. It's great to be here.
• 0:34
  I, gosh, it's a long story.
• 0:36
  I don't know how much time we have.
• 0:38
  Oh, you've got 60 second sound bites, Emily, I promise you won't keep it long.
• 0:42
  But first of all. All right. You started this way.
• 0:44
  Tell us about yourself. Tell us about your career.
• 0:46
  Then we're going to get very curious
• 0:47
  about how you helped us find the patient's voice.
• 0:49
  Tell us about your trajectory.
• 0:51
  All right.
• 0:51
  That sounds great.
• 0:52
  So I am Emily Boss.
• 0:53
  I'm a pediatric otolaryngologist.
• 0:55
  I'm at Johns Hopkins.
• 0:56
  I have been here my entire academic career since 2008, which
• 1:00
  now definitely makes me, next generation, I think so.
• 1:04
  So I started here as a really interested in clinical outcomes research, and I grew
• 1:11
  more and more interested in communication science and patient experience.
• 1:16
  I'm excited to tell you how that happened. Yeah.
• 1:18
  All right. So we know each other since when?
• 1:21
  When did we interview for residency?
• 1:23
  We interviewed for residency.
• 1:26
  You're really dating us.
• 1:27
  But that was like 2002.
• 1:30
  No, it would have been earlier than that.
• 1:32
  We I think we really met around the fellowship trail time.
• 1:35
  All right. Fine.
• 1:36
  So our 20 years we've known each other a big, big fan of yours.
• 1:39
  We're we're in the community.
• 1:41
  What is your title at Johns Hopkins?
• 1:43
  Just so we can put everybody on the same page.
• 1:45
  What are the various roles you have?
• 1:47
  If you can just tell us your titles.
• 1:49
  I'm a professor of otolaryngology, head and neck surgery, pediatrics,
• 1:53
  and also health policy and management, which is part of the Bloomberg
• 1:56
  School of Public Health.
• 1:57
  I am the director of pediatric otolaryngology in our Department
• 2:01
  of Otolaryngology.
• 2:03
  And then I also have some roles in utilization management.
• 2:08
  And I am the medical director
• 2:09
  for the Johns Hopkins Health System revenue cycle Management.
• 2:13
  And we're going to tease everybody.
• 2:14
  You're also a great author and I love reading your works.
• 2:18
  That's just hang on, everybody.
• 2:19
  If you want to know what we're talking about,
• 2:21
  we'll get there in about 10 or 15 minutes or so.
• 2:23
  It must be awesome.
• 2:24
  And you still see patients, right?
• 2:26
  I still see patients. I'm still operating.
• 2:29
  There's a lot of hats that are being thrown around.
• 2:31
  Yeah. It must be awesome to have the name “Doctor Boss.”
• 2:34
  “Don't worry, little Johnny. Doctor Boss is here.
• 2:36
  Everything's going to be okay. ” That's right.
• 2:38
  It is a good way to get to know your patients and the kids.
• 2:41
  But you are like a surgeon, boss.
• 2:43
  You're not a girl, boss.
• 2:44
  You're a surgeon boss, a professor of otolaryngology.
• 2:47
  There's not a lot of them at Johns Hopkins.
• 2:50
  And there's not a lot of female professors of surgery, am I right?
• 2:53
  That's true.
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  And I just want you to know I am proud to be a girl boss.
• 2:56
  So more the the older I get, the more I want to show that that is the case.
• 3:01
  And can we give you the lie detector test?
• 3:03
  Did we prep for this?
• 3:05
  We we didn't I tried to I everybody I reached out to him.
• 3:09
  What questions are you going to ask me.
• 3:11
  He was very opaque.
• 3:12
  So yeah very opaque because we we really want
• 3:15
  to understand your research, your clinical applications.
• 3:19
  I just read a terrific article that you wrote.
• 3:23
  Can you tell us where we found it?
• 3:24
  About the voice of the mother through tonsil.
• 3:27
  Why don't you start about that, then let's go backwards on the patient's voice
• 3:31
  and how it's crucial for us as surgeons.
• 3:35
  Yeah.
• 3:35
  I'll just say to you, because I know you've been in my shoes.
• 3:38
  The older I get in and the more experienced I am in practice.
• 3:42
  Every year is a new question of what should I do with my life?
• 3:45
  Or what do I want to be when I grow up?
• 3:46
  And and in the last couple of years, I had the great opportunity
• 3:50
  to participate in a fellowship that was hosted
• 3:54
  by the provost of the University for Public engagement.
• 3:57
  And so the provost had we had 15 different, different professor level,
• 4:04
  professor level
• 4:05
  faculty from all across the schools of Johns Hopkins University.
• 4:09
  I got to be one of two medical doctors.
• 4:11
  The other medical doctor is a psychiatrist who does something totally different.
• 4:14
  So it was a really wonderful experience in trying to learn about speaking
• 4:20
  to the public, about research and about our, our academic
• 4:23
  and our medical pursuits.
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  And what was fun is, again, there weren't that many doctors.
• 4:28
  So it's sort of like you realize how the public and patients
• 4:31
  are perceiving our specialty and our message.
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  And it gave me a lot of opportunity.
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  And one of the
• 4:37
  one of the training sessions we had was with the New York Times opinion editor.
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  And so we all wrote op eds, and he actually edited them
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  line by line in front of everybody.
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  It was very cringey, but also amazing experience.
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  And so it's given me some, some real interest in writing
• 4:55
  more publicly about the experiences that patients share with us
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  about our experiences providing health care.
• 5:02
  Back up a second.
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  Emily. Doctor Boss. So public engagement.
• 5:06
  Are we getting scored here?
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  Are you going to get a demerit for being on this “Voices of Otolaryngology”?
• 5:11
  Are they going to judge you?
• 5:13
  I don't think so.
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  I feel like everyone's too busy to know what's going on, but.
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  But, you know, we we need to.
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  We talk so much within our community of otolaryngology
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  and in academics, even smaller in our academic, insular world.
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  And we have so much opportunity to really interact with patients in the public.
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  And this has been your career interest.
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  You didn't wake up yesterday and get enamored with public engagement.
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  You didn't write that article. And where's that article?
• 5:40
  The most recent articles in HuffPost.
• 5:43
  Okay, HuffPost.
• 5:43
  And that was “The Mom’s Voice of the Tonsil.” That's right.
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  I had a really valuable experience, which I have all the time, where I
• 5:50
  was just in post-op regular day, and I talked to a patient's
• 5:54
  mom and a kid had just had tonsillectomy.
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  And I, you know, I mean, a lot of kids on the day of surgery
• 5:59
  because our advanced practice provider might see them in advance of me.
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  And she's just totally amazed, like, oh my, so I did the right thing, right?
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  So I was right.
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  I was right all along.
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  I was like, of course right. There's so much right.
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  He couldn't breathe.
• 6:14
  There was.
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  This took me forever because there was so much going on back there.
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  And and she just over and over again repeats how she's just so amazed.
• 6:21
  She was right.
• 6:22
  You have no idea how many people told me I shouldn't do this.
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  And then she went on and on about just her account, her whole journey.
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  She had been doing this for a year, trying to find somebody to listen to her.
• 6:32
  And there's all these different voices.
• 6:35
  Not just not just clinical voices either, right?
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  You're your spouse, your parents, your friends.
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  You have all this online information will tell you
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  these other things that you need to consider and why you might be wrong.
• 6:48
  And so, you know, and and once you pay attention to that, you realize,
• 6:52
  you see moms doubting themselves in so many different scenarios.
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  And that's true for for humans, right?
• 6:58
  Patients, people doubt themselves.
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  But this is particularly true for mothers who are taking care of their children.
• 7:04
  So I want to back up a second.
• 7:06
  Tell us about your training, your college undergrad med school,
• 7:10
  residency fellowship.
• 7:12
  Just walk us through that so we can build those connections.
• 7:16
  I went to elementary school here in Baltimore where I was.
• 7:19
  Go bring it on. Captain of the safeties.
• 7:21
  Okay, people.
• 7:22
  Good people respected me.
• 7:24
  When I help them cross the street.
• 7:26
  That's important. That's important for you to know.
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  And I grew up in Richmond, Virginia.
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  And then I went to college at Northwestern University, where I was actually a fine
• 7:33
  arts major. And
• 7:35
  when I
• 7:36
  was hanging out with all the liberal arts,
• 7:39
  my little liberal arts arts colleagues I saw reflected on my childhood.
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  So when I was a kid, I was nine and my younger sister was four.
• 7:47
  She had leukemia.
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  And and it was it was very traumatic.
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  And she is fine. She is a healthy adult.
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  We are great friends and and but I really reflected on
• 7:59
  what's it like for my parents to have a child with leukemia.
• 8:02
  Like, what was it like for my parents to field their, their friends and, and
• 8:08
  go through these moments of terror and, you know, try to work with me and my older
• 8:13
  sister and, you know, kind of guide us through this, this whole experience.
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  And, I don't know, I called my my parents.
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  I said, like, I'm doing it, I'm going to med school.
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  And they they actually just laugh.
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  They then called each other and laughed because I had very specifically
• 8:29
  said no science ever again.
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  And I took astronomy like it was literally astronomy
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  as a science, and I think it was called the Earth as a planet.
• 8:38
  It was geology.
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  It was also known as “rocks for jocks.” Not there weren't a lot of jocks
• 8:43
  at Northwestern, at least not the ones that I was hanging out with. But but.
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  So I had already taken those courses
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  so that I could just be done with science altogether.
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  So anyway, just to say that when you start something from beginning, you can do it.
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  So that was for how I got got into medicine, was this idea of thinking about
• 8:57
  how do parents experience disease in the eyes of their children?
• 9:03
  This is an awesome linear conversation.
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  So Richmond to Northwestern to?
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  To Virginia Commonwealth University.
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  It used to be Medical College of Virginia.
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  Okay.
• 9:12
  I, I did my general surgery internship at UCLA.
• 9:16
  I was back at VCU for residency.
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  I went to Seattle Children's for pediatric otolaryngology fellowship.
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  And then I came here in 2008, and I've been here since.
• 9:24
  Awesome.
• 9:24
  That's exactly perfect. Perfect.
• 9:26
  So you've been to premier institutions.
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  So at Johns Hopkins, you are a new faculty member, very active clinically.
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  And then tell us about your research.
• 9:36
  How did you help our specialty help medicine find the patient voice?
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  you know, when you receive those Press Ganey surveys that that you're supposed
• 9:46
  to talk about every element of your visit and how your doctor talk to you and.
• 9:50
  Yeah, how do you think I do on those, Doctor Boss?
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  I bet you do great.
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  Most people do great. That's what we don't know.
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  But well, we way back when, when I early in my academic career,
• 10:01
  we were getting those Press Ganey surveys and the, the organization was really
• 10:05
  prioritizing them and patient experience or patient satisfaction overall.
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  And we got like what I would call the “you suck report” all the time, right?
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  It was just this big grid of a lot of different red squares.
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  And sometimes you see a yellow and sometimes you see a green,
• 10:19
  and it just told you how much below the median score you were in terms
• 10:24
  of how patients felt about you and the experience that they were having.
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  And so so the department needed a champion for patient satisfaction.
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  And and, you know, I was sort of “volun-told” to be this champion.
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  And I got really into it.
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  I was getting a MPH at the time and I, I worked with, with Press Ganey
• 10:43
  centrally and got got some national data on patient experience and otolaryngology
• 10:48
  and, and I got to tell you, I said I kind of, I, I drank the medicine.
• 10:52
  I was really interested in patient experience or patient satisfaction
• 10:57
  as a science.
• 10:58
  You know, there's a lot of parallels to the consumer world in terms
• 11:02
  of how we're measuring patient experience
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  and how we should use that to influence our, our care and practice.
• 11:07
  What are some of the big findings?
• 11:09
  Okay, so so the question that they
• 11:12
  that we rely on a lot is would you return
• 11:15
  like: “would you come back to this physician or this clinician?
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  Would you come back to this practice?” And that's like
• 11:21
  the measure of loyalty, right?
• 11:22
  That means that you would drive two hours and you would wait for 45 minutes
• 11:27
  while other people are yelling in the waiting room,
• 11:30
  and you would pay for parking, because that's how much you value
• 11:33
  your experience in this practice or, or with this, this clinician.
• 11:38
  So that's that's a big one.
• 11:39
  And then there's also all these different elements of: “did you feel respected?
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  Like did the doctor talk to you in words that you could understand
• 11:47
  and taken individually?” These are sometimes hard to analyze,
• 11:51
  but but as a whole they actually mean something, right?
• 11:54
  I mean, we in research right now, we fund research that makes disease
• 12:00
  better, right?
• 12:00
  So we're really based very heavily on clinical outcomes.
• 12:03
  But this idea of going somewhere and feeling like, oh, I understood,
• 12:07
  I understood what he said.
• 12:08
  Or, you know, they, they they made me feel heard.
• 12:12
  Right.
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  Like those in, in their own right are outcomes.
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  So did you move yourself,
• 12:18
  the department, the hospital from red to yellow to green?
• 12:22
  Oh, maybe I think in in some regards, yes.
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  What I would tell you is we,
• 12:27
  we changed a lot of the way that we were looking
• 12:29
  at patient experience, at least within the department.
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  So we relied a lot on that patient voice.
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  And we did a lot of sentiment analysis.
• 12:36
  And we might have actually worked on a couple of these papers together
• 12:41
  back in the day.
• 12:42
  I mean, we look, you know, there's there are the questions that we answer,
• 12:45
  usually on a scale of 1 to 4 or 1 to 5, and most people will will get actually top
• 12:49
  box scores and anything that's not what they call top box,
• 12:53
  like the highest score you can get is usually a less optimal score.
• 12:57
  So but then there's also these segments where you can write a little bit more
• 13:01
  about your experience.
• 13:02
  And so those are just free text.
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  And and you can really understand how patients are feeling
• 13:07
  just by the emotional content that they put into those segments.
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  And so so we learned that, you know, like one thing I can tell you is that
• 13:15
  that people are so terrified of these, these reviews, but the far
• 13:18
  majority of patients have overall decent experiences in health care, right
• 13:22
  or right, it's not only patients that had a bad experience
• 13:26
  that are writing about it.
• 13:27
  And even though
• 13:28
  it really hurts to get a bad review and sometimes it actually is unfair,
• 13:33
  you know, sometimes, you know, what was happening on the other side.
• 13:37
  There's almost
• 13:38
  there are no experiences where we can't learn just a little bit
• 13:41
  about how somebody experienced their interaction with you.
• 13:45
  So, people believed in you.
• 13:47
  The administration, the government, you were significantly grant
• 13:51
  funded to look at this work.
• 13:53
  And I believe at a point in time, you're the only person exploring
• 13:56
  patient sentiment.
• 13:58
  Talk a little bit about your grants.
• 13:59
  We don't need the hypothesis and the aims, but kind of the big picture.
• 14:03
  You were significantly funded.
• 14:05
  And so people did find these valuable and found it of great interest.
• 14:09
  So the meat of of the funding or the meat of my research is now
• 14:13
  about how patients and physicians or or physicians and families,
• 14:17
  clinicians and families, I'm talking about clinicians, physicians,
• 14:21
  and all of our APPs communicate with each other, make decisions.
• 14:25
  And then how those how that communication and those decisions
• 14:29
  influence how care is deliberate, like how care is utilized.
• 14:32
  So do the does what we say.
• 14:34
  Can we say something one way or another way that would result in
• 14:40
  in a difference in how you make a decision for surgery, in whether
• 14:43
  or not you come back to the emergency room after your child has surgery.
• 14:47
  Right.
• 14:48
  Like, does it result in misuse or appropriate use of care?
• 14:52
  And that's been, that's that's sort of been the mean of it.
• 14:55
  We've had this awesome opportunity to audio record
• 14:59
  really at this point, over 500 different visits.
• 15:02
  These are just real time visits between between clinicians and children
• 15:06
  who are undergoing evaluation for elective surgery.
• 15:10
  It's usually tonsillectomy,
• 15:11
  the grants funded by the Heart Lung Blood Institute now.
• 15:14
  But but we've looked at different different elective surgeries and and
• 15:19
  then we've been able to analyze elements of those elements of communication
• 15:24
  and some of the outcomes, the the patient centered outcomes.
• 15:27
  Right?
• 15:27
  The ones that the parents, the parents are proxy for the patients,
• 15:30
  the parents are, are noting and then also the clinician centered outcomes.
• 15:34
  And then look at some of the objective ones too.
• 15:37
  It's very cool.
• 15:37
  That's a that's a big mouthful, but it's basically just showing
• 15:40
  this is what is happening real time and care.
• 15:42
  And then we also get to interview the parents after these,
• 15:46
  these these evaluations and say, and we'll play back
• 15:50
  the tape like: “what do you think at that moment?”
• 15:52
  Like is there something that was said here that made you want more?
• 15:55
  Or did you understand that?
• 15:56
  Or how did you like hearing
• 15:58
  this information or what happened here that made you trust somebody?
• 16:02
  What did you find in these 500 audio
• 16:05
  recordings for the surgeons?
• 16:08
  So what what are you generally hearing?
• 16:10
  What were sentiment analysis? What did you find?
• 16:13
  Give us some of those take homes.
• 16:14
  And and by the way, we've we've looked at them all as a whole.
• 16:18
  But this is a data repository.
• 16:19
  So we are looking at this ongoing.
• 16:21
  And so we've done these evaluations in different chunks of,
• 16:25
  you know, selecting encounters to evaluate for for different reasons.
• 16:28
  So all of this work is ongoing.
• 16:30
  But it won't surprise you right?
• 16:31
  Parents feel happy about care when they feel included in the decision,
• 16:36
  when they're made to feel like the decision is theirs to make.
• 16:39
  I'll give you an example.
• 16:41
  I have a patient that I saw and her child has a syndrome and has had,
• 16:48
  you know, he's been the health care system for a really long time.
• 16:50
  And I've I've operated on him.
• 16:53
  I've not operated on him. Right.
• 16:54
  I've won a few, I've lost a few or, you know, or sometimes we move the needle
• 16:58
  and sometimes we don't.
• 17:00
  And I look at her, I was like, what? What do you trust me?
• 17:02
  Like what?
• 17:03
  What is going on in this visit that makes you trust me?
• 17:05
  And she's just like, you just treat me like a person, and you talk,
• 17:09
  and you include me in the decision, right? So.
• 17:11
  So even in these situations where there's not a very clear decision
• 17:15
  or there's not a decision we can make that is going to make change or not,
• 17:20
  you know, it's
• 17:20
  this feeling of being included and feeling of being respected and heard.
• 17:24
  And we hear that over and over again.
• 17:25
  Something we do find often is that we the clinicians, because I'm imagining
• 17:30
  this is a heavy clinical audience that might be listening to this podcast.
• 17:34
  We, the clinicians, could do a better job saying, what do you want to do?
• 17:39
  Or what are you thinking about all of this?
• 17:41
  Or what is your biggest concern?
• 17:43
  Or even like, what is the one thing that brought you here, right?
• 17:47
  You know, we sort of assume that somebody has come in to see us for a problem,
• 17:51
  and our job is to evaluate and provide opinion and that that they've
• 17:56
  already worked through some of the, some of the, the emotional content or,
• 18:01
  you know, some of the priorities, but they that they haven't necessarily.
• 18:04
  And so really getting at like “what is the most important thing for you
• 18:08
  regarding this problem?”
• 18:09
  So like in the case of sleep apnea for children, it might be the
• 18:14
  the parent might say, I'm really worried about how
• 18:16
  my kid is doing in school or my kid has has behavior.
• 18:19
  And I'm kind of I want to do anything that's going to help that.
• 18:22
  They might say, I am terrified of surgery, right.
• 18:25
  And usually there's a reason, like, oh,
• 18:27
  because I have another child who had a bad outcome from something.
• 18:30
  Or, you know, a friend of a friend told me about this, this problem.
• 18:33
  Or they might say,
• 18:35
  my child plays sports or like, I can't take two weeks off of work, right?
• 18:39
  Like it's like this idea of taking time.
• 18:41
  So everybody has these different priorities in terms of, of of
• 18:45
  where they are.
• 18:46
  And that influences how they make a decision.
• 18:48
  And we, the clinicians have some capability
• 18:52
  of trying to direct that conversation.
• 18:54
  So we're we're helping the the helping to empower
• 18:57
  the the parent and the patient and making the right decision for them.
• 19:02
  So I think we're at the opposite.
• 19:05
  I think I'm brief and you're not.
• 19:08
  Yeah. We've known each other for two decades.
• 19:11
  No, no, because I got this I, this is what I wrote
• 19:13
  included respect heard and empowered.
• 19:17
  Are those kind of the big - is that fair?
• 19:20
  That is fair.
• 19:22
  And but I want what I do want to make clear is it's not just like here.
• 19:26
  What do you want to do, right?
• 19:27
  It's you.
• 19:28
  We we as clinicians are still obligated to and should be providing an opinion
• 19:33
  that is based on the best available evidence
• 19:36
  and our years of experience treating other patients
• 19:40
  with similar problems and and what we know and what's available to us.
• 19:44
  So patients do still want some clarity when they're leaving, right?
• 19:48
  I mean, I've said we talked about those comments on the patient experience survey.
• 19:52
  I remember evaluating one about
• 19:56
  about somebody
• 19:57
  actually, I think this was anonymous, but it said I appreciate that she she
• 20:02
  let me make the decision, but I am seeing her as the medical expert.
• 20:06
  I really want to know what what what I should do.
• 20:08
  So it's not like saying like here, here are all the balls,
• 20:12
  you know, here are all the options. What would you like?
• 20:14
  Right?
• 20:14
  We are still able to allowed to
• 20:17
  and should be providing an opinion with a “why.” Right?
• 20:21
  With a “why” attached to it. Like I think I would recommend this.
• 20:24
  And this is why.
• 20:25
  It's because what I've heard from you is such and such.
• 20:27
  Is that right?
• 20:29
  All right.
• 20:30
  I expanded my list: “included respect, herd , empowered, clarity, why.”
• 20:34
  Let's play a fun game.
• 20:36
  And it's not the one you think, Emily.
• 20:38
  It's going to be.
• 20:39
  What word is missing from that list?
• 20:41
  Watch this.
• 20:42
  Can can the camera pick this up? Let's see.
• 20:44
  Do you see this equation? Emily.
• 20:46
  This is good handwriting.
• 20:47
  That's great. Yeah. Thank you.
• 20:49
  Proportional to inverse time.
• 20:51
  You didn't mention time.
• 20:53
  It's really interesting.
• 20:54
  So I, I and I, I did the game with you twice.
• 20:57
  We can play it back.
• 20:59
  So did you find the length of the visit as an independent predictor?
• 21:04
  So, no, actually. That's my point!
• 21:07
  Yeah we're still working on that.
• 21:08
  But there and you probably - Don't keep working on it.
• 21:10
  I don't want to spend more time.
• 21:12
  Well this is in my, my this is, this is this is research of many.
• 21:16
  Right.
• 21:17
  There are ways that you can really provide presence
• 21:21
  and focus on a patient in the same amount of time.
• 21:24
  And in fact, sometimes more clarity, less conversation, actually, actually,
• 21:30
  you know, can result in the same the same outcome.
• 21:34
  Now, I will to the point of time, I will say
• 21:38
  there's more and more burden that we are experiencing all the time to,
• 21:42
  you know, like, so things that things are, are creeping in so that, you know, now,
• 21:46
  we're not supposed to be ten patients.
• 21:48
  You're supposed to see 15, maybe 16, right?
• 21:50
  Like like the number of patients per template or.
• 21:53
  Right, like the, the there are different systems. It's great.
• 21:56
  It allows patients access,
• 21:58
  but there's just there's just a few more things that we that clinicians
• 22:01
  need to do to tie up a visit and, and make sure that that happens.
• 22:06
  Now, I think you're the person who taught me who taught me this.
• 22:08
  It's like you can't look at them and say, yeah, sorry, I only have eight minutes
• 22:12
  here, so I cannot I cannot hear another concern
• 22:15
  you have about this surgery that I'm going to perform on you.
• 22:19
  You know, like we we spent a lot of time like looking at
• 22:23
  online shopping
• 22:24
  on Amazon for a coffee maker or something, right.
• 22:27
  Like how much time do you spend?
• 22:28
  But you'll go in for an eight minute visit and come out having signed your child up
• 22:33
  for for big surgery.
• 22:34
  So, so we can't look at them and say, yeah, sorry, this is all I have.
• 22:40
  But so there are some ways that we can try to provide that
• 22:43
  information before visit, after visit, you know, like provide links to to have
• 22:49
  further conversation or further reflection for the for the patient and family.
• 22:53
  Yeah, I have a quote I use.
• 22:56
  “Brevity doesn't belie
• 22:59
  interest.” Quite the contrary.
• 23:02
  And I think you got to that right.
• 23:04
  Just because you're brief doesn't mean you're not interested.
• 23:06
  What tips can you give our otolaryngologists?
• 23:10
  I'd say the vast majority of listeners are health care,
• 23:14
  whether they're medical students, young physicians, otolaryngologists.
• 23:17
  But we also have about 20% of the public listens to this podcast.
• 23:21
  But let's let's address the clinicians.
• 23:23
  What are some tips? And you mentioned it.
• 23:25
  You said it's not about the time.
• 23:27
  It's about the quality of the visit.
• 23:29
  You're in a very busy pediatric practice in Baltimore.
• 23:33
  Some tangible tips you give to surgeons or to others.
• 23:37
  Yeah.
• 23:37
  So first I just want to say, and I mean this: “doctors I hear you.” Okay.
• 23:43
  This is
• 23:43
  this is a really complicated time to provide medical care and clinical care.
• 23:48
  Right. Like the system is changing very rapidly.
• 23:50
  And, you know, health care as an organization.
• 23:52
  There's a lot of mistrust and misinformation.
• 23:55
  So we are up against a lot.
• 23:56
  AI is great in many ways and is also, you know, just in general.
• 24:01
  The World Wide Web can provide more for us to respond to.
• 24:05
  So that's just number one is: you're not crazy.
• 24:07
  This is this is all really happening.
• 24:09
  And it's a lot.
• 24:10
  Okay.
• 24:10
  Next next tip that I have is the “Purell moment.”
• 24:14
  So hopefully we're all doing some type of handwashing
• 24:17
  before every entrance and exit and and everything in between.
• 24:22
  And you might be an hour behind.
• 24:24
  You might be really frustrated
• 24:26
  with something that happened with a patient two, two sessions ago.
• 24:30
  You might have had a bad encounter with with somebody at the desk.
• 24:34
  You might have had an issue with your own child at home the night before.
• 24:38
  Right?
• 24:38
  But in those few minutes, while you're “Purelling”, it's
• 24:42
  actually hopefully it's just seconds, right?
• 24:44
  It's just this moment to say I'm
• 24:45
  going to reset and and give this next patient my full focus.
• 24:50
  Because what, what they are here for, it might be earwax, which
• 24:53
  just for all the patients with Cerumen that are listening to this
• 24:56
  I love Cerumen, okay.
• 24:58
  But like
• 24:59
  but you know
• 24:59
  for them
• 25:00
  that they've been waiting for this visit forever
• 25:02
  because this is a really big problem. Right.
• 25:04
  So so just having that moment of presence is key.
• 25:08
  Again, it's really just being very intentional about presenting an option.
• 25:13
  And you can also present doing nothing as an option.
• 25:17
  Right. It's not like here you can have surgery, you know.
• 25:19
  Or another option is this idea of watchful waiting.
• 25:22
  You know, where we give it a little bit of time and see.
• 25:25
  And then also just that, that final question of what's most important to you?
• 25:29
  Like, what are you scared of?
• 25:30
  What are you know,
• 25:31
  we talk about preferences and values as a part of shared decision making.
• 25:35
  That's another topic.
• 25:36
  But those are
• 25:37
  those are buzzwords right there, really hard to put a meaning behind.
• 25:40
  So let's let's give you some some ways to script that.
• 25:43
  Like “Doctor Shah, what is the thing that is bothering you
• 25:47
  the most about this problem?” Or “What are you most worried about
• 25:50
  moving into this decision and or what do you want to do?” Right?
• 25:54
  So so those are some practical tips for trying to get the best information
• 25:59
  in a short amount of time.
• 26:00
  We have some tools and opportunities now, right?
• 26:03
  Like, we can use the scribes that are presented to us, the ambient scribes.
• 26:08
  Like, we can make our templates better so that we're not focused so much on
• 26:13
  selective listening so that we write something down,
• 26:15
  you know, we can we can do things with our own visits
• 26:19
  and our own workflow that help move patients, move patients through, or help
• 26:24
  make it less overwhelming
• 26:26
  so that there is a little bit more time for that presence with the patient.
• 26:30
  What is that word you use?
• 26:31
  Selective listening. Can you can you explain?
• 26:33
  I know you're just thrown out
• 26:35
  all these NIH grant funded words, but I'm just a surgeon.
• 26:38
  What is selective?
• 26:39
  I barely listen, I mean, don't try to get me to be a selective listener.
• 26:43
  All right, well, let me ask you this.
• 26:44
  When you go to see a patient, do you are you writing it down
• 26:47
  or are you using a paper chart or use an electronic?
• 26:50
  Yeah. Okay.
• 26:51
  And then what do you do later to write down the problem that the patient had?
• 26:54
  Yeah. Go back to the EMR and chart it. Okay.
• 26:57
  And then you.
• 26:57
  But so now let's say you're an hour later right.
• 26:59
  You saw four patients in a row. Now you're.
• 27:01
  Doing my best.
• 27:04
  So hard.
• 27:04
  But you are basically going through
• 27:06
  this selective process of what did they say to me? Right.
• 27:08
  This is what I remember about that person. I.
• 27:10
  You probably already decided you already knew what you wanted to do within
• 27:14
  maybe 90 seconds of the patient talking or interacting.
• 27:17
  Right?
• 27:17
  And so you're writing that down. That's your that's your impression.
• 27:20
  That's how you perceive the patient, how they're talking to you.
• 27:23
  But that is selective.
• 27:24
  It's the same thing if you're actually documenting in front of a patient.
• 27:28
  Right?
• 27:28
  Maybe they're telling you their story and you know what you're listening for.
• 27:32
  So you're writing down the things that you think
• 27:35
  you need to write down right there in front of them.
• 27:37
  This is where these scribes might actually help us be more impartial, right?
• 27:42
  Like they actually hear the patient's story and synthesize it.
• 27:44
  So it's not up to us to write it down.
• 27:46
  It's just like sort of saying back what the what the patient said, but in a
• 27:50
  in a more comprehensive manner.
• 27:52
  So then your point is then the scribe or ambient scribe helps
• 27:56
  because I can then focus on shared decision making,
• 27:59
  presenting options instead of going down the heuristic of selective listening.
• 28:03
  Yeah, exactly.
• 28:04
  And also, it's a little more fair to the patient, right?
• 28:07
  Because it's not the scribe is not you're you're
• 28:11
  you're not choosing what to recall of what the patient's story is.
• 28:14
  Right?
• 28:14
  The scribe is trying to be more comprehensive.
• 28:17
  Now, if these scribes these they can introduce bias in their own right.
• 28:20
  But I don't know.
• 28:21
  I've been pretty unimpressed with clinical documentation.
• 28:24
  We do a whole lot of copy paste and forwarding, and we
• 28:28
  we put over and over again terms from a medical or medical record
• 28:32
  that don't need to be in there,
• 28:34
  that that one way or another may bias a future reader.
• 28:38
  You know, like I saw a chart, I do some of these chart reviews
• 28:43
  for Medical Necessity
• 28:44
  and one it was like for a child and it said History of maternal
• 28:48
  anxiety with cutting behavior, something like that.
• 28:51
  And so what's supposed to happen then if that kid comes back
• 28:54
  having a complication from surgery?
• 28:56
  Am I going to read that and decide that?
• 28:59
  And somehow this is a fabricated experience because of the mother, right?
• 29:02
  And, you know, like we see this all the time.
• 29:05
  Patients are talking about this too, right?
• 29:07
  We have open notes so everybody can access everything about their medical record.
• 29:10
  This is not a time for us to to present our, our thoughts about,
• 29:16
  you know, about the patient's, you know, the patient's
• 29:21
  disposition in life.
• 29:22
  And so, so people will read that, they'll say, like, I saw this thing in my chart.
• 29:26
  I try, I tried to get it scrubbed or I tried to contest it.
• 29:29
  That's a lot of work for them to do.
• 29:31
  So, you know, this is our time to really be as impartial as we can.
• 29:34
  My point just going back to the scribe is that can actually help look,
• 29:38
  that way you can focus a little bit more on
• 29:40
  like really trying to say, what would I do for this patient? Right.
• 29:42
  Like I really want to put myself in the shoes of this patient
• 29:45
  for these few moments that I have with them.
• 29:47
  So when probably about 15, 20 years ago, when we were looking at Press Ganey
• 29:53
  patient sentiment, patient experience, we would have glib advice
• 29:57
  from administrators. Oh, sit down,
• 30:01
  talk to them, look them in the eye.
• 30:03
  But the advice you gave
• 30:07
  regarding time, which was not on your list is reset.
• 30:11
  Give options. Shared decision making.
• 30:14
  Think about technology to help you with scribes and templates.
• 30:17
  It seems like we've evolved from the glib sentiment.
• 30:20
  Oh, just sit down and look the mother in the eye to more tangible.
• 30:24
  And that's probably your research.
• 30:26
  Is that a fair assessment to make?
• 30:28
  Well, what I will say, the glib sentiment one is it's really hard
• 30:32
  when a non-clinical person is telling clinicians
• 30:34
  how that how they should practice and relationship.
• 30:37
  I mean, many ways I'm saying the same thing, right? Like.
• 30:39
  Yeah, let me interrupt you there, but you nailed it.
• 30:43
  Hold on. That's really important.
• 30:44
  That's why you have credibility
• 30:46
  because people are like, “oh, Doctor Boss is one of us.” Right?
• 30:49
  You're at Johns Hopkins, you lead your division of otolaryngology.
• 30:53
  You see 30, 40 patients a day.
• 30:55
  You're exactly right.
• 30:56
  We get tired of the administrators.
• 30:58
  And I think that's the value and probably why you're grant funded.
• 31:01
  So sorry to interrupt that, but.
• 31:03
  I'll build on that.
• 31:04
  Yeah, I have this cool experience
• 31:06
  as working on in operations and other functional business of medicine.
• 31:10
  And like for example,
• 31:11
  in revenue cycle management, there aren't any clinicians on the team.
• 31:15
  Right?
• 31:15
  So sometimes I'll listen and I'll, I'll listen to the,
• 31:18
  the innovation or a solution that's being proposed.
• 31:22
  And it's like, oh, well, a doctor can write an order or,
• 31:25
  you know, we'll have to get the doctor to do X and X.
• 31:28
  And it's it seems obvious because it would take care of something.
• 31:32
  Right?
• 31:32
  Because we are interacting with the patient.
• 31:35
  This is the point of contact in the entire medical visit.
• 31:39
  But, but, you know, we have to stand up and say, wait, wait, wait.
• 31:42
  No, I'm, I'm a I can't do another thing.
• 31:44
  Right?
• 31:44
  Like, that is not my job to think about the visit class
• 31:47
  and, you know, the different payer policies, right?
• 31:50
  We don't know nothing flags.
• 31:52
  If I see a patient and I say, okay, let's do let's do surgery, nothing comes up
• 31:58
  saying this patient has, Aetna I'm sorry, I don't know anything about Aetna.
• 32:03
  But like so you must get this test right.
• 32:05
  Like we don't actually have that.
• 32:06
  Maybe some systems are more advanced than do right.
• 32:09
  We're just practicing.
• 32:10
  We're just practicing medicine the way that we're trying
• 32:12
  to practice medicine sort of universally for every patient.
• 32:16
  Yeah.
• 32:17
  That was a really well said.
• 32:19
  Couple more questions.
• 32:20
  And then I want to give you back to your administrative revenue
• 32:24
  cycle and your patients. So you know this was coming.
• 32:27
  Give us the “High/Low/Buffalo” on your research,
• 32:30
  on your two decades of patient sentiment, voice analysis,
• 32:36
  listening to the recordings, what's been the high,
• 32:38
  what's been the low and what's been the buffalo?
• 32:40
  The “buffalo” is the kind of unusual finding that somewhat surprised you.
• 32:45
  I could talk about the research itself, or I could talk about my experience
• 32:48
  as a researcher. So I don't know, my friend.
• 32:50
  You just get one “high.” Oh, man.
• 32:52
  Okay, well, the high is is really being able to influence
• 32:56
  how patients experience care if it's true and really talk to patients.
• 33:00
  I mean, look,
• 33:01
  some of some of being able to communicate with patients comes with time.
• 33:04
  Some people are natural, some aren't.
• 33:06
  But when you hear over and over again somebody's
• 33:10
  experience again, most are good, some are not, and a lot are constructive.
• 33:14
  You just become better.
• 33:15
  And so being able to think about like, how can we synthesize that?
• 33:18
  And make that an actual science so that so that this can potentially influence
• 33:24
  how somebody is is talking to patients or giving healthcare that is a high
• 33:28
  What's been a “low”?
• 33:29
  Give me a low.
• 33:30
  A low is: funding is a is a tough game.
• 33:34
  And anybody who's a clinician scientist knows this.
• 33:36
  But there are just so many different, administrative
• 33:42
  barriers and hurdles, you know, or like, am I going to get it this year?
• 33:46
  Or, you know, like even when you have the funding, you know, the it's cut.
• 33:50
  So, so that that produces some anxiety and distance
• 33:54
  and advises us to do the research. Right.
• 33:56
  So that's, that's probably not that surprising.
• 33:58
  Yeah. All right.
• 33:59
  So I want to shift a little bit now I tricked you.
• 34:02
  Look you you had a buffalo.
• 34:04
  You had a buffalo. Give it to us. Give it the.
• 34:07
  No I was going to give you another low like, well, maybe this is a buffalo.
• 34:11
  No. That's right.
• 34:11
  Just give me one more buffalo because I have a couple more questions.
• 34:14
  And I want to talk about your current work so quick “buffalo.” Okay.
• 34:17
  So the buffalo is is like the best, even with the best studies
• 34:20
  like the best design cohorts or randomized trials like we are
• 34:24
  still not understanding outcomes of patients
• 34:27
  like we have some opportunity through, natural natural language,
• 34:32
  NLP, like language processing and social media listening
• 34:36
  to really think about outcomes that matter to patients.
• 34:39
  Right now, the way that we measure them is
• 34:41
  we give them very long things to complete, and these are validated measures.
• 34:45
  I'm doing it, by the way, like this is how I'm conducting research.
• 34:48
  But I think we have so much more opportunity to think about long term,
• 34:52
  these things that we are doing to and with patients and recommending for them.
• 34:56
  I mean, otolaryngology is a specialty of so much elective surgery.
• 35:01
  Right?
• 35:01
  Like we just so much of what we do, even when surgery is not elective,
• 35:04
  or treatments not elective, there are so many different choices
• 35:08
  and combinations within, you know, within any disease process.
• 35:12
  Like I can talk about PEDs or any other subspecialty
• 35:15
  and give these examples of even when there are hard,
• 35:18
  hard lined clinical practice guidelines, there's still a lot of gray areas.
• 35:23
  We'll take that as a buffalo.
• 35:26
  You're a great writer.
• 35:27
  And so I want to end with what you're up to now.
• 35:31
  But but before I do that quickly, what's next?
• 35:36
  Regarding your two decades of research on patient sentiment,
• 35:39
  what are you doing from an academic perspective?
• 35:41
  Then I want to briefly end on on some of your writing.
• 35:44
  Thanks.
• 35:45
  We're we are going hard right now on synthesizing our
• 35:48
  our largest cohort so far is telling you we have that whole data repository.
• 35:53
  And we've done some pilot studies and we've dabbled here and there.
• 35:56
  But right now we're really working on looking at communication and engagement
• 36:01
  and what are like so that I can tell you truly
• 36:04
  what you can do to help your patient, but actually more so
• 36:08
  so that I can tell a parent or a patient, ask these three things in your visit,
• 36:13
  and you might be able to get more right sided care for yourself or for your child.
• 36:18
  Right?
• 36:18
  It's not like take take control of the system.
• 36:21
  I'm not trying to give a, you know, a let's overthrow kind of voice,
• 36:25
  but we have a lot more patients than we do otolaryngologists.
• 36:29
  Right?
• 36:30
  So, like, how can patients make the most of their 8 to 10 minute
• 36:34
  outpatient visit or their experience in a hospital, right,
• 36:37
  so that they are feeling comfortable about the care
• 36:41
  that they're choosing for themselves or their child.
• 36:43
  So you've moved on. We're going to end with this.
• 36:45
  You've moved on now to mass media to actually reaching the public.
• 36:50
  HuffPost is one thing, but you've written several articles.
• 36:53
  Where can people read about bringing your work to the masses?
• 36:58
  And they're beautifully written. Really enjoyed your work.
• 37:01
  Okay, well, check it out.
• 37:02
  There's a piece in in Newsweek where I talked about the The Pit, which,
• 37:07
  you know, I'm a big TV. TV show, The Pitt?
• 37:09
  The TV show The Pitt.
• 37:11
  But, you know, they they're not nice to otolaryngologists.
• 37:14
  And that's coming from somewhere. Right?
• 37:16
  So somebody had a bad experience that says “Head/Neck is pushing something
• 37:20
  off.” Right?
• 37:21
  We've actually, we, Otolaryngology, we've been cited
• 37:24
  a few times in these in this, this major television show.
• 37:28
  So so we need to think about that.
• 37:31
  Like it goes back to the patient experience survey.
• 37:33
  We can say all the reasons why that's not fair.
• 37:35
  Or we can say, hey, somebody had this experience.
• 37:39
  That’s how we’re Being perceived.
• 37:40
  Thank you for speaking up for our specialty.
• 37:42
  So Newsweek about The Pitt.
• 37:44
  Where else can we find some of your great writings?
• 37:46
  Oh, I just we just wrote one for Oprah Daily,
• 37:49
  and I wrote about my experience being a patient and how being a patient,
• 37:53
  being on the other side of the table
• 37:55
  really makes you deliver care a little bit differently, right?
• 37:58
  Because you realize all the sort of sound and not so sound
• 38:02
  things that you're offered and just how much uncertainty there is.
• 38:05
  And so like, for example, you really see how,
• 38:09
  how how somebody might say, this is what I do for my patients.
• 38:14
  And you say, well, why do you do that, doctor?
• 38:16
  Why? And there's like, because I have very good outcomes, but
• 38:19
  it's not based on, you know, it's hard, hard, hard line science and medicine.
• 38:23
  So kind of learning where those gray zones are has been, has been really fun.
• 38:27
  So keep your eye out.
• 38:28
  I'll keep I'll keep posting about these on
• 38:31
  on social media and on a website and, and.
• 38:35
  Just how can people find you Doctor Boss?
• 38:37
  They can find you through my LinkedIn.
• 38:39
  But there's probably a better way to see.
• 38:40
  How can they find some of your work?
• 38:42
  Yeah, find me on LinkedIn.
• 38:44
  I have a personal website, DoctorEmilyBoss.com,
• 38:46
  where I've been listening some of these public forays
• 38:50
  and trying to work with the public and other partners to, you know, to really
• 38:54
  partner on care and make our communication and decision making better.
• 38:58
  And I'm now on TikTok, so that's been really fun and very cringey
• 39:03
  for my 13 year old daughter.
• 39:04
  But but yeah, again, it's a great way to understand
• 39:07
  what people are asking about, like what people are responding to
• 39:10
  and how patients are experiencing the care that we provide.
• 39:12
  It's a it's a huge a huge opportunity.
• 39:15
  And and I'm excited to take it further.
• 39:19
  Well we started our two decade friendship and we've worked on research together.
• 39:23
  This was awesome.
• 39:24
  I really wanted to dive deep on understanding patient sentiment
• 39:28
  and the patient voice.
• 39:29
  And we thank you on behalf of Otolaryngology
• 39:31
  for advocating for our patients.
• 39:33
  I'll give you the final word and then we'll break from there.
• 39:36
  Doctor Emily Boss, thank you.
• 39:37
  Thank you for sharing your insights and your resource DoctorEmilyBoss.com
• 39:41
  where we can read some of your work.
• 39:43
  Emily. Final words. Oh. Thank you. It's. I've.
• 39:46
  I've loved working with you for a couple of decades.
• 39:48
  You've been a huge influence for for me.
• 39:50
  And you are for our specialty.
• 39:51
  So very grateful.
• 39:53
  That was so kind. Thank you. Emily.
• 39:55
  Thank you
• 39:56
  for listening to this episode of Voices of Otolaryngology.
• 40:00
  Subscribe to listen to more of these episodes
• 40:03
  wherever you listen to your podcasts, and definitely join us
• 40:06
  next time as we continue these crucial conversations.