Going From Patient to Person

Geoff Mitelman: Welcome everyone, my name is Rabbi Geoff Mitelman. I am the founding director of Sinai and Synapses and I’m here with Dr. Jonathan Weinkle, who is an author. He wrote a book called “Healing People, Not Patients.” Looking at his website also, called “Healers Who Listen,” it’s trying to be able to integrate some of the medical work into not just working towards curing, but also questions of healing and how do we build a relationship and a covenant between medical professionals and their patients. And that relationship is so critical for our health, not just our physical health, but our whole being. So Jonathan, welcome, I’m glad to be able to talk with you here for a little bit.

Jonathan Weinkle: Me too. It’s been a long time coming.

Geoff Mitelman: So I would love to hear a little bit about your and your work, and what drew you to it.

Jonathan Weinkle: Absolutely. So you know, I should start by saying that if you had come to me in college, I would have said that in 20 years, I planned to be sitting in your chair, not my chair. I was headed for the rabbinate, several family friends and relatives pulled me aside gently and told me that was no sort of job for a nice Jewish boy, and I should go into medicine instead. And after arguing with him for several years, I finally caved in and listened.

And really, it was from internally thinking that, you know, what I wanted wasn’t necessarily to be leading a congregation, it was to be leading a Jewish life – you know, all of the values that I’ve been raised with, all of the practices that I’ve been raised with, leading me through the right way to behave in the world. And I didn’t necessarily need to be up on a pulpit to do that. I needed to be out there doing something else, but doing in a menschlich kind of way. And so when I got into medicine, the first thing that I did was say, “All right, how can I do this Jewishly? Like, I want to be a nice Jewish doctor, but I don’t mean that I want to be the guy that, you know, your parents want you to marry, or that your parents want you to become. I want to do it right. I want to do it this way.”

So you know, I’ve been collecting stories and collecting ideas for this for years. I mean, I started med school in 1999 and I spent the summer of 2000, the Y2K summer, rotating with hospital chaplains, both Jewish and non-Jewish chaplains, trying to get at the spiritual side of things, and really came to the conclusion that there are a couple of fundamental ideas, and then tried to operationalize those.

And the biggest idea, is in the first chapter of Beresheit, that God creates humanity in God’s image. And the rabbis go, “Well, wait a minute, we’ve just been talking about how God doesn’t have a body, so what does that mean?” And you know, I came of age davening out of the Siddur Sim Shalom, and they excerpted those exact passages of “to be created in God’s image is to do all of acts of chesed that God does in the Torah, like clothing the naked, and visiting the sick, and burying the dead.” And so that’s what we do. And there’s a lot of opportunity to do that in medicine. Every single day, every single minute, we can be thinking “Well, what’s the behavior here that we’re supposed to be mimicking?”

But there’s also a flip side to that, which is that the person sitting across from us is also in the divine image. And so having the right amount of reverence for the person as a manifestation of divinity – and you know, I’m in the Jewish environment, so I don’t have to make the excuse “you don’t have to be Jewish” in this environment – that’s what I’m going to go with.

Geoff Mitelman: Well, what’s interesting is [that] I’m thinking about the distinction, and Martin Buber’s theology of an “I-it” relationship that often happens, of – I call my doctor because I need them to be able to fix my arm, or figure out what’s going on with whatever part of my body seems to be broken. And the doctor sometimes is like, “OK, I’ve got to get through x number of patients, and I’ve got to deal with the billing, and I’ve got to do with these different pieces there,” there it’s a very “I-it” relationship. What would that relationship look like if it was an “I-Thou” relationship?

By the way, I think it’s not necessarily a bad thing if it’s an “I-It” relationship between a doctor and a patient at times, because if you’re spending all that time in the deep philosophical interpersonal relationships, that also may have its own problems as well. So I think one question is when and how is it appropriate to be in the “I-It” relationship, and when and how is it appropriate to be in the “I-Thou” relationship?

Jonathan Weinkle: That’s a great question. There needs to be room to spend that kind of time with somebody, but it doesn’t have to happen every time. You know, especially once you’ve met somebody and shown them that you’re in an “I-Thou” with them, if they have an “I-it” kind of need, like they’ve got strep throat, they know you care, you’ve shown them that you care, you feel that you care. You can swab their throat and say “Hey, I’ll talk to you next week when we have a little bit more time to sit down and do this.”

When you are with your best friend, you know, you may spend three hours talking about “Do you remember when we went camping in Colorado?” or whatever. Or you may be like, “Hey George, I need somebody to move my couch from one side of the room to the other, and I can’t lift it by myself, I’ve only got five minutes before I need to leave for work.” And George comes over and you move the couch. You still love George, he’s still your best friend, but that wasn’t an “I-Thou” moment. But it’s an “I-Thou” relationship.

And I’m in primary care for a reason. I don’t want to spend, you know, 10 minutes with somebody and never see them again. I want to spend 10 minutes with somebody knowing that maybe next year, something either really awesome is going to happen, like they’re going to be pregnant, or something really terrible is going to happen, like their parent passes away, and they’ll need 45 minutes, or they’ll need an hour. Or I’ll need to talk to them, you know, 20 minutes at a time for weeks on end.

Creating the relationship – you used the word covenant, I can’t remember whether it was offline or during this conversation – there was a great piece that I read in researching the book that I quote in one of the talks that I give, by Harold Schulweis, back in the 70’s, when medicine was a totally unequal relationship – pretty much across the board, it was very paternalistic. And he said something to the effect of “You need to create this covenant where the patient and the doctor both recognize each other in the other” – that meant themselves in the other – “and recognize their vulnerabilities, recognize their needs, and agree that they have a mutual project of making the patient better,” making the person better.

And that’s kind of where I try to get to with people I take care of, is that we have a mutual project.

Geoff Mitelman: So I think everyone would agree that that is what the goal is. And I think most people would agree that that is often not how medicine is practiced today. So what are the barriers? Why are we in the place where we are, rather than the place where I think all of us say this is where we feel like we should be, and want to be?

Jonathan Weinkle: Right, and that’s a great question. So I’ll go back – the biggest barrier is the expectation of being “I-it.” You know, you talked about the patient being like “I just want this taken care of.” And you know, I get treated like that by the people I’m caring for occasionally, right – “just prescribe me an antibiotic, just complete this form, just do whatever.” Most doctors that I talk to, and actually most people in the health care system in general, feel like it’s the system that’s treating them like the “it,” like the clerk filling out boxes on a form, like the person who has to meet all of these benchmarks, even if they don’t actually translate into real, high value care. And that gives them less and less time.

For me, the thing that most constrains the relationships is time, is the demand to see more people. And I’m lucky, because I work in a nonprofit community health center, where the only real demand for seeing more patients is coming from the patients – like, I need to get in sooner. But a lot of people are working for places where they’re getting productivity bonuses, and “productivity” just means they see more patients in the same time. And it cuts the visits down to very, very short periods of time. And they still have all the same requirements. So increasingly large bites out of their time that are being taken by documentation, by tighter schedules, by all of these other things, by decreasing reimbursements – is the biggest reason why that doesn’t happen. But that’s not the only reason.

Geoff Mitelman: I was going to say, I’ve have been thinking about – I remember reading Daniel Goleman’s book about emotional intelligence and the importance of emotional intelligence, and the connection that doctors should have towards patients. And sometimes it becomes almost viewed as a bit of a hippy-dippy way, but he talks about a bottom line piece of this – of malpractice insurance, and suing the doctor. That it’s not necessarily what the doctor does, but it’s rather, as a doctor, about the relationship with the patient. Because if there’s something that happens where there’s been a mistake by the doctor, if they don’t have a relationship with the doctor, they’ll say “I’m gonna sue that doctor,” but if they feel like “oh, this is somebody who cares for me,” they’re going to be less likely to be able to sue, and so it actually helps the bottom line of the hospital or the medical practice as well.

Jonathan Weinkle: Right. And it’s interesting because the people who are most worried about getting sued have the most reason to worry about getting sued.

Geoff Mitelman: Right.

Jonathan Weinkle: If that’s foremost in your mind, it’s probably because you have an adversarial relationship with the person, and you practice accordingly – you practice a lot of defensive medicine, you do a lot more stuff and do a lot less talking. And when you do talk, you talk at rather than with. Talking like that is sometimes referred to as an “information dump,” where you tell somebody a bunch of stuff because you know you have to say it and document that you said it, rather than giving them the information that they feel they need, or that they want to know, in a way that’s digestible for them. You’re reading the form letter.

You know, so I was saying that one of the things that happens is other than time is this idea that, you know, you said “it takes a lot of time to get to that.” And sometimes it does. But there are there are doctors who are naturally emotionally intelligent. I don’t think I’m one of them, based on things that I’ve learned from friends, colleagues and loved ones over the years. I had to learn how to be this way, and it took a long time. But in learning that, there are people who are just naturally that way, who can walk into a room and don’t need 30 minutes to dig deep and get into the real reason – like, what is somebody really afraid of when they’re coming in? What’s the real unasked question that’s not going to be asked until you put your hand on the doorknob? They can see it in somebody’s eyes, they can sense it in their body language, they can phrase one question perfectly and everything comes spilling out.

One of the things that’s the post-book project that I’m working through now, as I go out and I talk with people, and I meet with people, and I think about what’s the next step, is a lot of the book is about operationalizing this idea of very practical things about listening – asking good questions, right, the classic Jewish story, right, “Nu, did you ask a good question in school?”. But that’s a legitimate thing, asking good questions. Even when you don’t want to know the answer to the question, you have to ask it anyway. How to phrase your words, how to use nonverbal communication, all of that is there, but the real operationalization is how do you cut out all of the not-so-useful parts of the encounter and get to that straight away? And actually, I have some really interesting meetings with people coming up where that’s the project we’re working on. What’s the way that if we’re in covenant, we can come together and say OK, lock eyes – here’s what we have to accomplish.

Geoff Mitelman: Mhm. So yes, what are some of these ideas, to be able to scale this up and operationalize some of these opportunities here?

Jonathan Weinkle: Right. So I mean, the question people always ask me is “so, should we be lobbying, should we be doing this, or whatever?”. Institutional change takes a really long time. So the first step might be [to] start at the small institutional level, you know, look around you –  and don’t just look at your own behavior.

One of the biggest problems with change is that everybody’s like “we should be more empathetic – doctors, more empathetic.” And they give us all these seminars. And I was online last night in a chat with a bunch of other medical professionals, and we were talking about – some of the nurses were talking amongst themselves about how they keep getting these like, you know, sort of warm and fuzzy trainings, but then still carrying seven or eight patients a shift and not ever seeing the inside of their break room.

It can’t all be on the provider. It can’t all be asking the patient to be a better self advocate. The institutional policy that says the visit is 15 minutes may have to change to 20 minutes. And somewhere along the line, the dividend of “yeah, we’re seeing a few less patients per day,” but eventually some of the return visits of frustrated people that are like, “I can’t believe you haven’t fixed this yet” will stop, and you’ll be able to see somebody new, or you’ll be able to do something else in that time that wasn’t there before, because you won’t be seeing the same person for the same problem over and over again, getting progressively more angry. You might need an institutional policy that trains reception staff, or that trains the pharmacies, or that trains somebody else in the same way.

I’ve talked a little bit about building better relationships between providers. One of the things that medicine is notorious for is that it’s very hierarchical, and the doctors are, you know, traditionally, we’re usually male, usually gruff, usually not from a minority and – you know, stuff rolls downhill. And so if they got angry, they got angry at the nurses or whatever, and the person who is at the bottom of the hill, with everything crashing down on them, is the patient. And so flattening the hierarchy and getting people talking with each other like this, and instead of at each other really makes a difference. Doing those kind of concrete things in your little corner of the world is one way to get it.

Geoff Mitelman: I’m also curious, we also talked at the very beginning of the conversation – what are some ways in which your Judaism has influenced this philosophy and the way that you look at this relationship here?

Jonathan Weinkle: Sure. So I mean, I talked about the initial idea that I came with, the idea of a covenant. Rabbi Schulweis’s idea speaks to me very greatly. That you know, one of the ways that human beings are imitating God is that we’re both looking at this kind of as a partnership relationship, where we have obligations to each other, right. You know, American society is based on rights – like, patients have rights, doctors have rights, employees have rights, everybody has a right, something that they’re expecting to be given to them. This is more an idea of us being obligated to another, of us saying “I promise you that I will do this for you. I will be by your side if you’re dying. I will be present for you if you’re suffering. I will call you in two weeks to check and see how you’re doing.” And putting yourself out there as having an obligation towards someone, as basically being bound by mitzvah to take care of someone. 

So if you’re talking about “I-Thou” instead of “I-It.” “I-It” means you come in, you find out what the symptoms are, and prescribe a medicine. “I-Thou” means you are visiting the sick, and visiting the sick means that you’re taking time to be present with somebody, even if you don’t say anything, and not just, you know, flip some switches and turn some dials, but really be present for somebody. And I think that makes a big difference. The same group that I was talking to online last night, I used the term “accompanying the dying” or “accompanying that dead” and they said wow, that’s so powerful. I said that’s levaya tomet, that’s the Jewish term for being at a funeral, but it actually since the word hamet can mean a dead person, a dying person –  it’s an adjective, it’s a verb, it’s all sorts of things, it’s future, past, present – you’re present through that whole process, including that, you know, for that matter at the moment when somebody gets a potentially fatal diagnosis that they eventually recover from, you’re present too. And people remember that. And people are less likely to treat you as an it if you don’t treat them as one.

Geoff Mitelman: Absolutely. You know, I think if people wanted to learn more about this way of looking at healing and doctor-patient relationship, what are some things that they could be looking at or talking to their medical professionals [about]? Or if they are medical professionals, talking about patients? What are some practical takeaways here?

Jonathan Weinkle: Right. So there’s a bunch of practical takeaways. Some of this stuff will eventually go up on my site, but there’s a few things that I use regularly. One is to try and be as open-ended as possible. The less you go in with a checklist, and the more you go in opening yourself up to somebody, sharing what’s really on their mind with you, it really helps you. I talk about a lot about open ended questions, a lot about listening for what somebody is really saying. I will often, at least in my mind, even if I don’t ask them explicitly, use what are called the Kleinman Questions, which were developed by Arthur Kleinman, who is a psychiatrist at Harvard in the Refugee Trauma Program going back to the mid-70’s. Kleinman is trying to get at people’s life-world – not the way things translate into medicalese, but the way things are affecting them in their house, in school, you know, in the community, when they’re trying to buy bread at the supermarket, at their jobs. And maybe also some spiritual and cultural meaning of things that we don’t latch on to.

I try very explicitly to negotiate an agenda with a person at the beginning. There’s really good hard data out there about when there is either discordant agendas between the provider and patient, or when there just isn’t an agenda set at all, and the degree to which somebody is satisfied and, you know, feels whole with the care that they got drops by about 30%. If they don’t have a set agenda at the beginning of this, you know, that it’s basically a coin flip if you don’t, and it’s above 80% if you do. Figuring out during the course of the visit, like – reflective listening. This is a big, important thing.

You know, I think of the conversation between God and Avraham over a stone. “Well, I’m going to do it if it’s this many people.” “But what if it’s this many people?” And there’s this bartering back and forth, and there’s multiple exchanges of “let me see if I heard you right, let me see if I understand what’s going on.” And I do this with people when I’m prescribing the medications, like, “Wait, do I have to take that every day?” “Yeah, it’s pretty important to take it every day.” “I’m really not really good at taking it every day, what if I miss a dose?” “Well, as long as you get at least five doses a week, we should be OK.” “All right, do I have to take it in the morning, or can I take it at night?” “You can take it at night, it’s OK.”

And we go back and forth, so there is this mutuality in negotiating the plan as well. And knowing that somebody is going to get closure and isn’t going to be abandoned – I think of the verse from the tehillim that’s in the Yom Kippur liturgy, about, you know, “don’t abandon me in my old age, don’t forsake me.” It happens over and over again. That’s what people are wanting to hear in an age where, you know, their insurance company might change, and you say, “well, I can’t see you.” 

This especially is a problem here in Pittsburgh, [where] we’re having a fairly heated legal and legislative battle over whether the two health systems have to see each other’s patients. People are scared that  – even if they love you, and even if you’re relating to them on this, you know, very deep level, that they’re not going to be able to see you in a year. And you have to make some promises and reassurances – “I am not going to drop you”. Hopefully you can – hopefully you’re not bound by some higher power (who is not The Higher Power) to say, “no, you’re not allowed to see me.” And that’s one of the things where it really makes it hard, is because the relationship is not always under your control. We’re trying to find ways, in the narrow space that we’re given, to use the title of another book that came out last year that everybody should read by my friend Elisha Waldman, called “This Narrow Space.” You’re in a very narrow space as a doctor, and you’re in an even narrower space as a patient, especially if you’re sick. To try and make as much happen as possible in that space is really challenging, but you gotta do it.

Geoff Mitelman: Well Jonathan, that’s why the work that you’re doing is so interesting and so important, and the value of how do we think about healing in a radically different kind of way that’s actually going to get us where we need to be able to go.

So thank you for taking the time to talk here. And if people want to follow you, they can go to healerswholisten.com. And I think that’s also your social media sites as well, correct?

Jonathan Weinkle: Facebook is Healers Who Listen. Instagram, which I don’t use much but I will be starting to on someone else’s advice, is also Healers Who Listen and Twitter is Healers Who Listen without the E because there was a character limit. 

Geoff Mitelman: And the book is called “Healing People, Not Patients.”

Jonathan Weinkle:  And it’s available on Amazon and apparently the turnaround time is now only about 2 days, I would love to have people read it and let me know what they think.

Geoff Mitelman: Well thank you for taking the time, and even more importantly, for that important and amazing work that you’re doing. So thank you very much.

Jonathan Weinkle: And thank you for running such a fascinating organization, I really enjoyed jumping in here.