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In this episode, interventional physiatrist Francisco M. Torres shares a poignant story about missing the signs of depression in a patient. He reflects on the challenges of limited time with patients in modern health care and the importance of truly listening to patients and paying attention to what is between the lines of their symptoms. Tune in to hear more about the consequences of limited doctor-patient time and how to prioritize patients’ mental and emotional well-being in health care.
Francisco M. Torres is an interventional physiatrist specializing in diagnosing and treating patients with spine-related pain syndromes.
He shares his story and discusses his KevinMD article, “Not listening carefully to a vulnerable patient can become a matter of life or death.”
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Transcript
Kevin Pho: Hi, and welcome to the show. Rate and review at KevinMD.com/rate. Subscribe at KevinMD.com/podcast. Today we welcome back to the show Francisco Torres. He’s an interventional physiatrist, and his most recent KevinMD article is titled “Not listening carefully to a vulnerable patient can become a matter of life or death.” Francisco, welcome back to the show.
Francisco M. Torres: Thank you, Kevin, for having me again here.
Kevin Pho: Well, you’ve been on the show multiple times, and for those who aren’t familiar with Francisco’s story, just go to KevinMD.com/podcast, upper right-hand corner, search for Francisco’s name, and listen to his story. Before we jump into this particular article, just tell us a little bit about what you practice.
Francisco M. Torres: Well, I’m a physiatrist by nature, but I’m fellowship-trained in interventional pain management. My practice is outpatient, doing pain management, including procedures under fluoroscopy guidance. And I have my side business, which is wellness and my passion. I started doing that 20 years ago, and I spend at least 20 to 30 percent of my time on that, along with administration.
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Kevin Pho: All right. When you say wellness, how is that incorporated into your practice?
Francisco M. Torres: Because there’s a very good correlation between pain and overweight or obesity problems. Almost every patient that I see who has pain is overweight, and they lack exercise, and then they always blame the pain for not exercising. So there’s a lot of education. I spend time trying to avoid depending on pain medications and trying to get them a little bit more active with physical therapy, exercise, and proper nutrition to block inflammation.
Kevin Pho: All right, so let’s talk about one of your more recent stories. It’s titled “Not listening carefully to a vulnerable patient can become a matter of life or death.” Now tell us, how did this article come together?
Francisco M. Torres: Well, this is a story that I wanted to share, but it happened 20 years ago. I was just trying to run my business and trying to keep my practice afloat. The situation, as a matter of fact, was a couple that I had known for several years, very, very close together. Then the wife came to me one day to tell me that her husband had passed away. I remember that he had lung cancer, so he was in a lot of pain for six months. She just came to tell me that, and she left.
She had another appointment to see me for something not related to that, a musculoskeletal problem. Later on, when she came, you could tell that she was still sad, devastated, and very briefly she mentioned that she had decided to join a marathon in her husband’s honor. I was busy, I have to say. She mentioned that to me, and my subconscious mind said, “How can a woman in her 60s suddenly find her passion for exercise and running?” Even though she mentioned that, I just took care of her musculoskeletal problem and let her get out. So I didn’t spend the time to dig deeply into why she was running a marathon.
Eventually what happened was that I saw her later on, several months later, and she was rejuvenated and full of energy. She was just fantastic. We were talking, I was so excited for her, and then all of a sudden she said, “Oh, Dr. Torres, can I share something with you?” I said, “Of course.” She mentioned that the intention of running the marathon, because she was so depressed, was to kill herself. She thought that because of her condition, she could die right in the marathon. Whoa. That was like, I missed all the signs and symptoms of depression. That was really my moment at that time.
That’s the story, and I wanted to share it with you because nowadays we’re talking about how doctors don’t have the time to spend with the patient, because they have other business: electronic medical records, taking care of authorizations. A lot of the clinics, including my clinic, depend on ancillary services, other professionals, to take care of the patient, and the time the patient has with the doctor is less and less. I think there are going to be some consequences for that, and I try to bring that to attention. I think what happens is that we try to be there mentally, but most of the time we’re not. You know, we listen to the symptoms, but we don’t listen to what they’re telling us between the lines.
Kevin Pho: So after you heard that this particular patient ran that marathon to try to kill herself, tell me, when you first heard that, what went through your mind?
Francisco M. Torres: Well, I have to say I felt, I don’t know, because it happened 20 years ago, I think I felt scared. I thought, “Wow, imagine the outcome.” Even though I’m not liable for that, I think deep inside I would have been responsible for that death. That’s my fear. I would just have had to deal with guilt for the rest of my life. So again, I saw that as a second opportunity to correct the way I interact with patients.
Kevin Pho: So tell me, what kind of changes did you make as a physician?
Francisco M. Torres: Well, the first thing was I need to take more time to listen and show empathy. I have to give the patient the opportunity to express their feelings, and take the necessary steps in time to really recognize the signs and symptoms of depression, which is so common. And always remember that the nature of my work is easier at times if we are more involved with what the patient needs or is telling us. I have to be aware that there’s always a real cry for help if we dig deeply and ask the right questions. So I think those are the things that I learned.
My recommendation for everybody is to create more time with patients and minimize redundant and pointless tasks, and to always remember the quality of care is related to time, or quality time, not just physical time, just quality time. I think that it’s time to bring back that essence of care, where the physician-patient relationship is at the top of the model. So we have to listen to their stories. Also, I tend to do this: I tend to control the interview. I have to start slowing down and let the emotional agenda flourish, and again, ask open-ended questions and try to pay attention to their feelings. That’s basically what I learned from that.
Kevin Pho: Now, over your decades-long career, what kind of questions do you find are most effective to ask patients, to try to get them to open up or to uncover something that may not be immediately obvious? Any questions that you find are particularly effective?
Francisco M. Torres: Well, I think it is the way you enter the room, most of the time. I think this is a common thing with patients: They feel that I don’t have the time, that they’re in a rush. They say, “I know that your time is valuable.” The first thing I do is slow it down, and I say, “Hey, you’re the only patient right now. I have all the time.” Once I establish that, the patient feels a little more open to relax, and then they are a little bit more open to start sharing some of the information that they need to share. Also, what I do is start asking open questions: “How do you feel about this situation? Do you have any other issues at home that may be interfering with your recovery?” So I try to bring in a little bit more of what’s going on in the social part than just the symptom part.
Kevin Pho: So this particular story that you mentioned was an atypical presentation of depression. Any other things that you’ve garnered over your career that kind of surprised you and made you say, “Hey, this is depression”? Any other symptoms that were similarly atypical, like this one, that you want to share with us?
Francisco M. Torres: Well, I think you see in this example that all of a sudden they’re doing something outrageous that they were not used to. So I think rather than just saying, “Oh, good luck,” or “Good job,” we have to say, “Why, at your age, are you now starting to exercise this much, when you never considered that a priority?” I think that would be one question that you can continue to follow. Or with other patients who change something in their life, I want to know exactly how they feel and why they made that change.
When I do a little wellness on the side, I always say, “Why do you want to change? Why do you want to lose the weight?” When you keep asking all the time, after a while, it’s “Because I have a new boyfriend, and I don’t want him to leave me,” or “I have a family reason,” or “I feel so bad about myself,” self-esteem. So now we can open the conversation to more of the psychological part of that question.
Kevin Pho: One of the things that you mentioned earlier was how important spending time with patients is, and you don’t need me to tell you how valuable that time is. Now, a lot of physicians’ time is being taken away from them, right, from the electronic medical records, from administrators who want physicians to see more patients. What could we do as individual clinicians to take that time back? Is there anything that we can do on an individual level?
Francisco M. Torres: I think, again, we need to strive to really listen. That’s what I can tell you, because my training allows me to identify a medical condition within seconds in certain cases, you know, all the time. For example, a spinal compression fracture: I just talk to the patient, “What happened?” and I can just see it. It only takes two minutes. I do the X-ray and confirm it. But unfortunately, we’re not trying to identify signs and symptoms of depression or social issues, because they don’t have to be depressed. They can have a very serious social issue, and if we don’t address it, it’s really interfering with the recovery. That’s basically what I try to do.
I was talking to you before we came in, and we’re talking all the time about burnout syndrome. We talk like it’s unique to the doctor, but it’s not unique to the doctor. Everybody has burnout syndrome, but the thing is, how do we handle that burnout? So I like to have a plan. This case brought that to my attention: Yes, if I identify depression, what do I do? Do I call a hotline? Do I Baker Act the patient? It’s not only that I identify the depression; it’s how I handle that. So I have to have a plan: Either I have a hotline, or a psychologist’s number, or a psychiatrist. It’s not just identifying the problem. We have to know how to react to that problem.
Kevin Pho: Now, if you were to replay this whole scenario from 20 years ago in your head, and she said that she was going to run a marathon, and you did take the time to stop and ask her more questions, because it was uncharacteristic behavior, what would you have done next? In your ideal situation, what would you have done next?
Francisco M. Torres: I think that I would have explored more of her feelings about trying to kill herself, and about her purpose in life. I think I would have told her, or at least tried to convince her, not to run the marathon to kill herself, but to do it for cancer or for her husband. So I would try to redirect the purpose of that marathon, in a more positive way, not negative. That was probably it. And then I would have helped her, I think, to try to get in touch with a coach or a trainer, and then talk about her way and be sure that she was going to be successful.
Kevin Pho: We’re talking to Francisco Torres. He’s an interventional pain physiatrist, and his KevinMD article is titled “Not listening carefully to a vulnerable patient can become a matter of life or death.” Francisco, what are some of your take-home messages that you want to leave with the KevinMD audience?
Francisco M. Torres: Number one is to pay attention and listen to the patient carefully. I don’t think that we can evaluate or compare the time spent with the patient; it’s the quality of time. I think that you just have to be focused. I know that we all have issues at home, but at some point we just have to develop that tenacity to say, “OK, when I’m with a patient in that room, that’s the only person in my life right now. No distractions,” basically.
Kevin Pho: Francisco, thank you again for coming back on the show and sharing your time, story, and insight.
Francisco M. Torres: Thank you, Kevin. Have a great week.
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