Non-judgmental empathy in the exam room [PODCAST]

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“I think we all have an inclination—at least from time to time—to judge others. No matter how experienced, compassionate, and professional we are as physicians, we’re still human. I can admit that I have indeed struggled with patients like the 65-year-old morbidly obese male who complains at every visit about how hard it is to control his blood sugar levels with the medications prescribed. I want to convince him so badly about diet and exercise, but I have tried, and often, these patients don’t want to hear it. Pharmacological or surgical interventions are the preferred route for many.

I know I cannot magically change a patient’s attitudes about their health. Nevertheless, I still believe that the best I can do for my patients is to offer them my sincere professional advice without prejudice or discrimination. If my physical presence is intimidating to some, I won’t begrudge them for seeking a doctor who makes them feel more comfortable. In the end, I still believe that leading by example is essential for a physician and that I can use my personal experience to inspire positive change. After all, I am here to help.”

Francisco M. Torres is an interventional physiatrist specializing in diagnosing and treating patients with spine-related pain syndromes. He is certified by the American Board of Physical Medicine and Rehabilitation and the American Board of Pain Medicine and can be reached at Florida Spine Institute and Wellness.

He shares his story and discusses his KevinMD article, “The importance of non-judgmental empathy.”

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Rate and review the show at KevinMD.com/rate. Subscribe at KevinMD.com/follow.

Today on the show, we have Francisco Torres. He is an interventional physiatrist, and he wrote the KevinMD article “The importance of non-judgmental empathy.” Francisco, welcome to the show.

Francisco M. Torres: Thank you, Kevin, for the opportunity.

Kevin Pho: We’ll get into your article in a little bit. First off, share your story and journey to where you are today.

Francisco M. Torres: Well, it’s an interesting story. I was born in Spain, and then when I was five or six years of age, I moved to Puerto Rico. So I finished my education in Puerto Rico, medical school and residency at the VA hospital, and then I moved to the United States. I did a fellowship at LSU as a musculoskeletal fellow, and then I moved to Florida, and I have been here for the last 30 years.

My road has been interesting, because part of my reason I wrote this article is because growing up, I was exposed to so much anxiety. I was bullied because of my weight. I was ashamed of taking my shirt off, and all this trauma lasted for a long, long time in my life, during medical school, my residency, and my career. So I got to a point where I didn’t know what to do. I always thought that, you know, people who had six-packs and were fit were just genetically gifted. But deep inside, when I was growing up, it was interesting: I always watched Charles Atlas. I saw this guy doing just isometric exercise, and I said, “One day I’m going to be like that.”

So when I turned 40, for my 40th year, I said, “I have to change.” I was like 50 pounds overweight, very sedentary. So I made an incredible transformation. I was able to get my six-pack, but it only lasted three months. After that, I went back to the same pattern. And then eventually, in 2008, one day I woke up with chest pain going down to the arm. The bottom line, short story, is that after $10,000 of tests, my cath was normal, and they said, “You’re overweight, you’re deconditioned.” So I said, “I have to change.”

That’s when I got certified as an age management physician. I went through that course, and I became my own patient. Then once I changed, I became that person, and I was able to maintain that until just recently. I can tell you a little bit about that: Through the pandemic, I became a victim of that pandemic, and I went back, and I had to redo it again. So I learned a lot.

So going back to the article, it was interesting, because, you know, I have my book that shows my before and after picture, which is 50 pounds before, and then a six-pack, well, you know, super athletic. But I thought that people could, you know, see the message that I was not like that all my life. So this woman, you know, a little bit disturbed, comes and sees me. I see her as a new patient, no complaint, but then she calls later, an hour later, saying that she wanted to see a new physician because I was too fit for her. She was a 50-year-old with a broken body, and she said that I could never understand her. And I said, “Well, I’ve never been asked to refer a patient based on their appearance.” I was in shock, you know.

So it made me think: Am I just sending that message that I’m too judgmental, that they’re not good for me, that I cannot understand them? And I said, “I have to evaluate how I’m presenting myself.” So that’s why I wrote the article. I said that, you know, we as physicians have the obligation to show that we care about health and to be fit, but I think too much pressure, on the other hand, may intimidate these people, and I think there is a fine line. So I kind of started reevaluating the way I present myself to the patients.

Kevin Pho: Yeah, so you talk more about that story in your KevinMD article, titled “The importance of non-judgmental empathy.” So like you said, you talk about the story of a patient who saw you and wanted to switch physicians because she thought that you were too fit. So what was your initial interaction with that patient like? And did she give any impressions that she was unhappy or unsatisfied or wanted to switch?

Francisco M. Torres: Oh, no. She was very pleasant. The only thing, she was the typical patient. I do pain management: pain all over, a typical fibromyalgia type of situation, a very difficult life, you know, abuse, a social situation that was horrible, and she was fed up. You know, I understand her, but she never, ever said anything about the books. She never said anything about me personally. I thought it was just a perfectly normal interaction.

Kevin Pho: OK. And then when you heard about that request, tell me about what that was like for you, and what was your first reaction?

Francisco M. Torres: Well, it was painful, I have to say. I get a little bit emotional about that, because I wrote my memoirs based on trauma and growing up in so much judgment. And when I see somebody telling me that, and I’m fighting that, I’m trying to walk away from that, and she thought that I was going to do the same thing that they did to me, oh, it was very painful, very painful.

Kevin Pho: So what happened next after she made that request?

Francisco M. Torres: I never saw the patient back, obviously. I never pursued her. I never called her. But it changed my approach. And so I decided to start focusing more, because, Kevin, I am the kind of person that, when I put something in my mind to do, I do it. But then I started figuring this out: My typical patient is not like that. They have a lot of excuses. They have a lot of situations. So I cannot be strict with them like I’m strict with myself. I have to kind of mellow down my talk.

As a matter of fact, like I said, when I published my first book on weight, it was a typical weight loss book, you know: You follow the rules, you cut the calories, and you lose the weight. But there are like 20,000 books out there on diet that say the same thing. So now, what I decided to do, I said, “What do I do differently that other people don’t do?” And it came to me. I do a lot of psychology. I took my mind in order to eliminate my desire to eat this or do that, or the exercises. So I said, “Why don’t I put this in a book?” And that’s what my new book, coming up next month, will be: the epigenetics and the psychology of weight loss, how to lose weight quicker. And that would be just using the psychology.

Kevin Pho: Sure, sure. So tell me what kind of specific changes. You said that you had to reevaluate yourself. You think that this interaction was particularly painful for you. So in the exam room, tell me, what kind of changes specifically did you make?

Francisco M. Torres: Well, I decided that, first of all, I started greeting the patient, saying, “Hey, this is myself.” And then if they see the books, I say, “I had a very rough, you know, childhood.” And even when they read my memoir, they say, “Oh my goodness, you were able to expose yourself. You’re being brave.” Yes, because I have to tell them that there is a weak part of me.

The first thing I tell them is that I struggle, and I say, “I know exactly where you are. It’s very hard to change, but, you know.” And I kind of emphasize, “I don’t want you to have to have a heart event in order to change. I want you to do that before.” So I try to explain to them in the beginning that I’m part of them. You know, I’m not an elite athlete or anything like that.

Kevin Pho: All right, so let’s zoom out a little bit. So you’re an interventional physiatrist. You also specialize now in age management. So walk me through a typical day of your practice. What kind of typical cases do you see, and some of your treatments and therapies to help them?

Francisco M. Torres: Well, finally, after all these years, because my main practice is pain management, what I did was incorporate that pain management with the wellness. So what I do is, when I have my patient in pain, in addition to doing the procedure, the epidural, everything that I normally do interventionally, we talk about how we can approach their issue with their inactivity, which is a lot of them, they’re not exercising, and their weight.

So we talk about the story. You know, again, I use my example, because many years ago, I was told by a physician that I have a bad back and I could never, ever run or do exercises. At that time, you know, it was because I have spinal stenosis, whatever. And I tell my patients, “Look, probably my MRI is worse than yours.” What I did was push myself, and with this way of understanding the principles, I try to guide them in that direction.

And I have to say, I have a couple of my patients who were completely, really, heading for surgery, and they have lost a lot of weight. They’re very athletic. I have one in particular that I’m going to mention in the book. He just lost like 60 pounds after bariatric surgery, and he’s very happy. He’s still doing the pain management, obviously. I’m not promising a cure, but definitely much better, more functional.

Kevin Pho: So I’m a primary care physician. I do internal medicine, and of course, I see many, many patients with chronic pain. So what are some tips that you can share with primary care doctors like myself that we could incorporate in the exam room? One of the things that you mentioned was incorporating wellness as part of your therapy. So what are some ways that we can do that as well?

Francisco M. Torres: Well, the main thing is, because I’m so big with exercise, I started to try to eliminate that fear about exercise, because they all feel threatened. I felt threatened going to the gym, being with all these big guys doing that. So I started very, very mild with that. I said, “Hey, look, I know that you have all this limitation, but there’s no reason why, while you’re brushing your teeth, you cannot squat, or while you’re watching TV, you can go to the back of the couch and go up and down, do wall slides.” You know, so I try to make every single routine that they do during the day. And the reaction is, “Oh, I need to think about that. Oh, yeah, I have time to do that when I’m washing the dishes, I can.” So I go through trying to eliminate the fear of the exercise. That’s my number one rule.

Number two, I explain that exercise is not for weight loss. It’s only 5 percent or 10 percent at the most, but it’s fantastic to maintain the weight once you lose it. You know, once you reach that goal, boom, you can just do a lot, eat a lot, and still maintain the weight if you exercise to a certain level.

And then the other thing I tell them is that it has to be part of their life. Whatever I teach them is something practical. Like, “I know you have to go to a restaurant, but then when you go to the restaurant, start drinking the water first. Don’t get up at night.” So we talk about daily things that they can do in their everyday life.

Kevin Pho: We’re talking to Francisco Torres. He’s an interventional physiatrist. His KevinMD article is titled “The importance of non-judgmental empathy.” So, Francisco, again, just from the lessons that you learned from this encounter that you had with a patient, you talk about non-judgmental empathy. What kind of tips, again, can you share with clinicians about being non-judgmental in the exam room?

Francisco M. Torres: I think that we have to, at least for me, once I walk into the room, have a very clean mind, an open mind, and not try to impose my way of thinking on the patient. And I think I haven’t heard this in your previous podcast: We have to listen to the patient. You get 99 percent of the information just by listening to the patient. Sometimes we’re in a hurry. We say, “Oh, you’re fat, or you’re overweight. That’s why you have pain.” And that’s not true. You know, that’s not true. It may be interfering with the recovery, but it’s not the cause of your pain. So I’m always open-minded, and I try to be sure that they talk to me before I start opening my mouth.

Kevin Pho: And my final question: What are some of your take-home messages that you want to leave with the KevinMD audience?

Francisco M. Torres: Again, I think that it’s very hard to say that we are completely objective when we see the patient. I think I have to say, I have my biases. I think that even though I may not open my mouth, my demeanor may be insinuating that I’m judging them. So I have to be so careful with that. That will be my thing: Be careful with your gestures, how you present yourself, how you approach the patient, how you greet them. And then be comfortable with them from the beginning, because, you know, it’s not going to be a good relationship.

Kevin Pho: Francisco, thank you so much for sharing your story, time, and insight. Thanks again for being on the show.

Francisco M. Torres: Thank you, Kevin, for the opportunity.

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