Rapport Building

Preston: [00:00:00] Hello. There is a tabby cat on my desk right now. Hello. I like problem to have. You can go and sit down. She has been very excited to play. So I've been having my friends come over and do shifts doing fishing rod with her because she has this insatiable need To chase stuff and I thought I had a lot of energy.

I do not have as much as this kitten So I hopefully she'll sleep well tonight. Yeah 

Margaret: So 

Preston: Margaret, how are you doing? 

Margaret: How am I doing? Well, it's October 1st today when we filmed this Which I don't know if I should [00:01:00] say, but it's to me, October, amazing month. I am a Libra, so good month ahead. I think for me, how are you doing?

Preston: Um, I'm, I am an asthmatic and. Honestly, fall doesn't bring a lot of good things for me.

I use my inhaler a lot more. Uh, I think I'm a Capricorn. 

Margaret: I don't know that much about you. Actually. 

Preston: I was, I was actually hoping I could go to Oktoberfest and 

Margaret: as 

Preston: a dumb American. Yeah. Oktoberfest starts in September. 

Margaret: Yeah. It like 

Preston: ends the first week of October. I was like, oh, darn it. So. You're just 

Margaret: gonna casually.

So I'm in San 

Preston: Antonio, and they have a ton of German, like, heritage stuff here. 

Margaret: So 

Preston: I might go to like a neighboring town for their versed fest. 

Margaret: Wait, that's kind of, 

Preston: uh. Have their Apfelkuchen, because I took five years of German in high school. 

Margaret: Did you? Wait, what made you take German? [00:02:00] 

Preston: So my mom said that we were German.

Margaret: Okay. 

Preston: So I was like, I'm gonna get in touch with my roots, right? That was all I had in my mind. Yeah, and it's funny, you know, because having that German heritage is something that lets you bond with someone when you meet them and you don't even know who they are. You're like, wow, look at this. We're both enjoyers of bratwurst and apple vine.

Margaret: I feel like I have rapport with 

Preston: you now, is what I would say to them. That was a pretty cheesy, but that's what we're talking about today is rapport. 

Margaret: Transition. That was so smooth. I didn't even know it was happening. 

Preston: I know. And so I did it last time too. I was like, Hey, I feel like people are attached to this title.

And you're like, yeah, that's the thing about being attached. And then you like went on a whole rant about feeling it. And I was like, I was like, Hmm, I wonder how we can attach this to our topic. 

Margaret: Do you ever think I just didn't like that one? And so I purposely didn't pick it up. [00:03:00] 

Preston: No, I didn't. I didn't consider that to be a possibility.

I was like, he's too genius. I'll remember that. 

Margaret: A mystery to let simmer. 

Preston: So what, tell me about your relationship with rapport in patients. 

Margaret: Um, I think that rapport is the reason that I thought I could be a doctor, which is a hot take a little bit. But by what I mean by that is, I think like rapport is a big part of what everyone says.

And they're just like, I just like connecting with people and I want to help people. La la la la la. When they go, you apply to med school. Um, but I think rapport is kind of if you can build it, if you can hack it through the beginning of trying to build it is like one of the really, really meaningful parts of medicine in general and psychiatry specifically.

Now, what does building rapport look like? What do you think of it when you think of building rapport? 

Preston: I don't even know. what rapport is, to be honest. 

Margaret: Okay. 

Preston: I think [00:04:00] everybody feels like they know what it is. And I think for a long time, I thought rapport is just someone liking you. Like, does the patient like me?

And that was actually my goal when I first got into med school. I was like, By golly, I'll get this patient to like me. 

Margaret: You went to an interesting field after that. I did, 

Preston: yeah. So, it's funny, the, I have this vivid memory as an M1. We were doing our, like, first, like, practice patient scenarios. And we had, like, an OSCE and this patient simulation.

And we were, we would go watch. Back like as a class or like 10 of us in our little clinical skills scenario. You remember these classes? 

Margaret: Yeah, they're traumatizing. 

Preston: And so we're like, okay, let's watch Laura's footage. And it was like hilarious because Laura was like, now I'm going to like pull out the tray and help your feed.

And she like couldn't figure it out. So she's just like awkwardly fiddling with the, with the clinic chair for like. A painfully long 90 seconds and [00:05:00] and she's not making conversation during any of this and you can like, you're like muttering under her breath and we, we watched all 90 seconds of that and I was like, I was like, Oh, okay, this is cool and then I watched the next person and everyone's being like very serious and like calm with the patients and then we get to me and I'm just like landing joke out of joke so, so this, I would, yeah.

I went straight from college into med school, so maybe I was like a little bit too rambunctious here. But I remember, I think that the actual patient must have been probably in her 80s, but she was like a simulated patient who was like 85 or 

Margaret: 90. 

Preston: And I was like taking a sexual history. And I said, Oh, like, you know, are you in a relationship at all?

And he was like, no, I'm single. And then there was a pause and I was like, well, it's never too late to find someone, you know, get out there. She started laughing and then she broke character. She was like, son, can you say that? I was like, I don't know.

But I was like, what attachment style do you have? [00:06:00] Yeah, I was like. If I can make this lady laugh, then we can have a poor and so it's funny, like even on my feedback, like later in my, um, Oski's, I went through med school was great job building rapport, but like work on this other stuff. And my professor even told me at our, like, and meeting, she was like, your superpower is like.

How you like want to engage with patients and interact with them, but I was even that I was like confused by it because I'm like, well, they like me, but like, is that also a good thing to try to be liked by your patients? Like, because I had other people, especially in psychiatry, say, well, you want them or even surgery to you want them to respect you or just like you or or feel like they can trust you.

Margaret: I 

Preston: think all those kind of go into report and there have been aspects of report. I think I've missed it. When I'm just like kind of on this mission to, to get someone to, to smile a little bit while there are a lot of benefits to making someone laugh, I wonder, I kind of like [00:07:00] reflect on it. If I'm achieving those other things that I trust, 

Margaret: I guess I think of rapport is also being like, yeah, what you're saying of like trust, which like, yeah.

Putting someone at ease like in those first interactions is a big part of that of just being like, hey, this isn't going to be horrible and awkward for you and you're not going to necessarily immediately hate me. Um, but then also like rapport, especially in what we do, is like, Building the trust that you're there and can react and like kind of a tune and hear all the sides of their health that they might have want to talk about, including the things that are like, hey, doc, I don't think the meds working.

And I'm kind of afraid to tell you that. Cause like you felt like it helped last time, whatever. 

Preston: Yeah. Um, I'm afraid to disappoint you. 

Margaret: Yes. Yeah. 

Preston: That's interesting. And. It'll be kind of like guide how like we define rapport is going to guide how we pursue it, right? So if [00:08:00] if your definition of rapport is just does the patient like you then you're gonna do everything to pursue that But if you need to have the patient feel safe with you and and have them trust you and can rely on you Then then you're changing your target and now you're working in a different direction 

Margaret: Yeah, so I guess, I think, you know, obviously both of us are psychiatry trainees, so it makes sense why we're talking about this, um, but I also think that this is an important question for like the broader, like, health, like both of us start as like, you're saying like M1s, and I also remember my like standardized patients, we had one that was like, how do you break bad news, basically, and there was some wild thing we all said to try and do that the first time.

So I feel like this is like a really important question throughout Bye. Healthcare, not just in mental health. 

Preston: Yeah, and I think as we learn like what's okay to say and what's okay not to say, and anyone who's in a patient facing capacity, it's, it's a unique relationship, the provider and the clinician, you're, you're not someone's friend, but you're also [00:09:00] more than just a professional relationship.

It's, it's, it's, it's its own beast, 

Margaret: which is also I'll say disorienting. To learn how to be the person in that role and like figure out what does it mean to connect with your patients and be yourself, but also be professional and consider the power dynamics that are happening in the room, um, and to try to build a relationship that is not like any other type of relating that you've ever done before in your life.

Preston: Yeah, yeah, because I see people that try to be too paternalistic, or almost like draconian. Like, I'm the doctor and you will follow my instructions, and other people that try to be almost like too buddy buddy. 

Margaret: Yes. And, 

Preston: and like I, I always kinda like try to think where do I fall? Mm-hmm . Within these, these categories and like, how is my style working for me?

Margaret: Mm-hmm . 

Preston: So kind of, I, I have a fun [00:10:00] paper I found in looking back at the history of rapport. Mm-hmm . I was Oh, you went deep in the archives. 

Margaret: You got the lore. I did. 

Preston: I was so, I, I type into Google like. Patient clinician rapport and effect on outcomes, basically, and I was going through some papers and I found this one from 1979.

It was a study on the physician patient relationship and rapport. And so I just want to want to read you from this abstract, this wonderful conclusion they came to. While it is not yet clear how rapport with patients can be achieved, evidence reviewed here suggests that a physician's ability to establish rapport with patients is at least partially dependent on his communication skills.

Margaret: Damn. 

Preston: Well, 

Margaret: I guess you're saying I should stop bullying my patients. 

Preston: So they figured out in 1979 that your communication has something to do with your ability to have rapport. And then they, after that, they go. This is important because [00:11:00] implications for teaching physicians the elements of empathetic communication are discussed here and can have significant impacts on patient care.

Margaret: You heard it here first, folks. 

Preston: So in 1978, they were like,

shut up. I'll be doing, I'll be asking the questions here. And then in 1980, they're like, Hi, how may I help you? When they discovered that rapport actually helped people. 

Margaret: In 1969, we went to the moon and in 1979, we discovered, what if we were nice? 

Preston: Humans have emotions. 

Margaret: Like now, hold on a second. 

Preston: Yeah. Every seventies doctor with their brass knuckles watching this abstract come out and they're like, no, I 

Margaret: can't 

Preston: punch them anymore.

Margaret: I will say though, at that time in residency, shout out to my dad who was in residency at the beginning of the eighties. Close to when this paper came out, they were still working 36 to 48 hour shifts. So, uh, empathy in that setting, difficult, [00:12:00] really tough, really tough stuff. But yeah, but also this is like a, like, I feel like rapport is a great example of at that time, like in, in 1979, but also ongoing this, like.

The sort of quote unquote like softer humanities or social sciences side of health care and outcomes and that it matters, but to prove that we kind of have to figure out a way to codify it, which I don't disagree with, like, I don't think we should just be able to say things and be like, just trust me, bro.

Like, that's also not good. Um, but like, it's one of these parts of like, how do we prove that this matters to care so that make people value it so that it goes into how, like who goes gets to become a doctor. 

Preston: Mm hmm. Yeah, it's fascinating. Medicine deals with these almost Self evident truths 

Margaret: that 

Preston: being nice to your patient, having a good relationship with them is going to lead to a good outcome and we jump over nearly insurmountable scientific hurdles and scrutiny to try [00:13:00] to capture these vague subjective ideas and pin them down and make them like psychometric rubric so that people can learn from them.

Can measure them 

Margaret: and this matters actually, 

Preston: yeah, it's like people only acknowledge that rapport matters if you can put it on a bell curve and pop out a P value consistently. So actually I pulled up some of the ways that we, we measure rapport and so I was going to read off like some of the questions that they have patients answer on these things.

So this, this is what I found 

Margaret: as if Preston's my doctor, 

Preston: this is one that's called the trust and physician scale. All right, Margaret, are you ready? 

Margaret: Yes. 

Preston: I, so agree or disagree. I doubt my doctor really cares about me as a person. 

Margaret: Disagree. 

Preston: Double negative. Nice. My doctor is usually considerate of my needs and puts them first.

Margaret: I'm not going to answer all of them [00:14:00] because it's going to, I'm going to show I'm biased towards doctors because I come from a family of doctors. Oh, okay. 

Preston: Yeah. So I think a lot of these are, it's getting at like, I trust my doctor's judgment about my care and I have this belief that they want the best for me.

All these are kind of broken down to like agree disagrees. I'm looking at the standard deviation and they all just like, 

Margaret: is there one on efficacy? Like one over around my doctor 

Preston: Yeah. 

Margaret: Has the ability to impact my like 

Preston: course. So there might be the, there's like the Barnett report questionnaire. There's, there's like five or six of these and another one is called the patient doctor depth questionnaire, the pd DDQ.

And this one goes more into the strength of your relationship rather than how you feel about how they treat you. So these questions are, I know this doctor very well. My doctor knows me as a person. He takes me seriously. He really cares. I know what to expect from them. I feel relaxed with them and I feel they accept me the way I 

Margaret: am.

Preston: So I think honestly this could be applied to any kind of relationship with [00:15:00] someone and you can insert doctor there or you can put in 

Margaret: dentists podcast co host. 

Preston: Yeah. Um, Baker, even McDonald's drive thru employee, like, I think that the person making my Fenty double shot knows what to expect when I pull up my SUV.

I don't think it, I don't think it applies, um, in the Starbucks scenario, but the point is rapport can be attempted to be measured, but we're also just kind of taking things that we are aware of, 

Margaret: and

Preston: Reconstructing them with some of that spits out a number and they, they, they all kind of apply to this disagree is zero points until he gets four points and we try to get this aggregate score out of it. And then you find out the people answered four is more often, do they do better to get better outcomes or their doctors?

Getting higher. I've used [00:16:00] who knows. 

Margaret: Mm hmm. Mm 

Preston: hmm. Actually, I know I was, I was the same way. Do you want me to tell you, 

Margaret: I did not catch that one. I'll admit that. 

Preston: So tell me the reason why. Oh, I am here to tell you the answer. So when we study, we use these things to try to measure rapport and then we kind of go and take a look and say, okay, how did these scores affect?

how our outcomes look in rapport. There's this one paper where they looked at multiple factors in people's therapy outcomes. So they looked at the demographic use of, um, like modality experience of the therapist. And rapport was one of the things they measured. And the strongest predictor of Successful therapy outcomes was rapport with the therapist.

Yeah. Yeah. So what they found was that [00:17:00] they could better than any other metric of prediction say, Okay, if they had good rapport, that's, that's the most powerful thing we have of guessing that they're going to have a good outcome of therapy. 

Margaret: And the surprising thing 

Preston: was he was even over the modality used.

So whether using CBT or psychodynamic. Rapport came first. 

Margaret: Yeah. Almost as 

Preston: like 

Margaret: rapport or like therapeutic alliance being the term in psychiatry. 

Preston: Correct. 

Margaret: But that the relationship was primary in some way. 

Preston: And I don't think maybe it's not helpful to view it as as primary, but almost the mediator necessary to deliver the care.

Uh huh. Uh huh. One, one thing that I've been kind of like adapting in this, like, almost like proceduralized view of like a therapeutic clients or, or psychiatry is that [00:18:00] when I'm like delivering supportive comments or invalidating or I'm affirming before we discuss these like painful and complex emotions, it's almost like you're anesthetizing.

Margaret: Hmm. 

Preston: The like kind of local area. So it's like, okay, me, me, like affirming this person that they've done a good job coming to therapy before we talk about their shortcomings. It's like a little bit of lidocaine before I try to do this incision and drainage. And if we have a good therapeutic alliance and you trust me to go in with the needle, we're going to get out the tumor, 

Margaret: you 

Preston: know?

So, so I think is the fact that you can numb the area is that king or is that just it's You What enables you to actually go in with a therapeutic intervention, and I think that's, that's kind of how I'm interpreting it is the therapeutic alliance is the reason why CPT can work. 

Margaret: Yeah, I think if you think outside of psychiatry to like.

If you think about like blood sugar control and in diabetes, or you think about blood pressure control that [00:19:00] the people who can trust like their primary care doctor in whatever way that looks like tend to have tend to, you know, anecdotally, I think clinically, I couldn't tell you the exact paper though, but like they also tend to have these better outcomes if I'll Google it 

Preston: right now, patient adherence, right?

Yeah. Blood pressure, rapport. Let's see 

Margaret: what comes 

Preston: up. A critical review of medical adherence and hypertension. Okay, you want any guesses on the outcomes? 

Margaret: Uh, P value, significant, positive. As in like, better rapport, lower blood pressure. 

Preston: No, really? Yeah, correct. Turns out patients that adhere more to their blood pressure medications They have better relationships with their doctors.

Margaret: Da da da da da. Although, this is a good time to say like, uh, They're Sometimes Preston and I will talk about things, and I try to avoid this trap, and I think both of us try to avoid this, but like, when we're talking about mental health stuff, I feel like a logical fallacy can be like, [00:20:00] It sounds like that would be right, uh, based on, like, current thinking, and that that is not, like, I think sometimes there's a lot of that where it's like, well, like, if A is true, then B, therefore, we can say C, but that the science maybe can show A and B, but not C yet, and I feel like that happens a lot in, like, Some of this stuff.

So I thought for a second that you were saying it wasn't, and I was about to be proven wrong on my saying, like, it sounds like it would be that. So I wasn't, I was right, but still, you know, a point where I probably easily could have just like misled people because I just kind of was like, that kind of sounds right.

Preston: Yeah, 

Margaret: anyway, that was an aside. Sorry. 

Preston: No, I know I think we fall into those traps a lot Where I think what I see is we go through all the scrutiny to find out a fact and then we're like I could have told You that yeah, when we get the results and so then the next thing that I could have told you I just assume is right, right, which is not true.

Margaret: Yeah. Yeah, 

Preston: and I think we make a lot a lot of those [00:21:00] assumptions If you don't anchor it in the scrutinized research opens up to a lot of bias because there are things that like end up surprising me as being like the greatest factor that that affects things like suicide risk, for example, I think when you hear that firearms are the most common way people complete suicide or therefore like the greatest risk factor 

Margaret: or 

Preston: modifiable risk factor often for someone I'm like, I could have told you that a firearm is like designed to be lethal.

Margaret: Yeah. 

Preston: Then on the back end, if you were to ask me, okay, like who has more, who attempts suicide more men or women, I could be like, you know, I think men do because they're alone and they're probably isolated and that sounds totally right, but it's false. 

Margaret: Yeah. 

Preston: Women attempt more. 

Margaret: Right. Or you could like reverse with this example, be like, okay, I could easily say like, well, the people who attempt the [00:22:00] most are the most likely to like die by suicide.

To succeed. 

Preston: Yeah. 

Margaret: Yeah. And that wouldn't be true, but it would sound like it would be true if there wasn't a study that, you know, is reviewed ad nauseum in psychiatry residency, so we know it's not, but yeah, anyway, this, I feel like this is a core concept that's going to come back in the podcast over and over of like, hopefully us filtering out the 

Preston: noise.

Margaret: Yeah. 

Preston: And then when you find something that stands up to the noise, you're like, that's obvious, but there's a lot of things that seemed obvious that are also incorrect. Right. A lot of things. And that's hard for poor, you know, when you find out. That having a good therapeutic alliance is helpful, like I could have told you that, but then you ask the doctor from 30 years ago and they're like, no, scaring your patients is what really gets through to them because I told the patient, like I listed off all the reasons why he was going to die if he didn't stop smoking and he finally stopped smoking and that's my evidence as to why, like my main strategy is just to shame my patients.

Margaret: Right. [00:23:00] Well, and also that they're like right now, we would say, I think sometimes like. As therapy, I'm about to have a hot take as therapy has like gotten online more and like been more in the pop culture that like sometimes there can be an impulse that like therapy is just supposed to feel all like validation and in some ways that makes sense, right?

Like in some ways it's like, yeah, that does like it should make you feel good. But what we know is that for some things it's not that it should make you feel bad, but sometimes like Moving more towards, like, a life that matters to someone means having to endure some pain and therapy not feeling good. So, like, just to compare, like, them then to us now, like, there's probably part of us that's kind of wrong in the opposite direction, too.

I would agree. So, like, the question then, I think, in therapy is often, like, Well, will any relationship or any, if someone, if you build rapport, build a relationship with anyone, [00:24:00] is that the thing that's changing? And then does it have to be a therapist? Does it have to be whatever in our field, at least? Um, and the difference between placebo or like a relationship alone versus like a relationship that is in healthcare and where like therapy is happening.

Preston: And I think it's almost like a catch 22 because if we define rapport by just do you like them a lot that relationship can be with anyone, but if we kind of look at these questions to capture a part of it, but really good ideas, does this person truly understand me? Do I trust them with my care? Do I feel like I can be open with them and safe with them?

That's really hard to get outside of the therapist relationship and it's going to be with someone who you're very close with. And. Who has a lot of emotional intelligence 

Margaret: or 

Preston: can interact with you in that way. So I think while anyone can have that relationship, it has those qualities. The therapist is someone who's trained to do that.[00:25:00] 

And it's, it's funny you bring up like that kind of like placebo therapeutic alliance duality because there's this other paper. So this is, um, from 2013. By Verhulst. So it's the medical alliance looking at placebo and the alliance effect. And they found that the medical lines that the patient, the provider have has a separate and measurable impact from placebo.

So if I have a good relationship with you. And I'm taking a placebo. That'll be different than if I'm taking a placebo and I have a bad relationship with you, but you're telling me that the medication will work. 

Margaret: Oh, interesting. Yeah. So that gets into this, the mediating factor of us as psychiatrists, but also anyone in healthcare who's like prescribing or implementing an intervention of it.

The [00:26:00] effectiveness is impacted beyond just like the suggestibility, correct? 

Preston: And so I think a lot of people will say, Oh, you know, my, my psychiatrist gave me this antidepressant and I'm feeling better on it. And maybe it's just the placebo because it's only been seven days or something as someone they hear a lot and.

Part of it could be placebo because you're anticipating the drug will help, but another part of it is the therapeutic alliance, and I think we see that those are separate, and the relationship that the patient has with their provider is going to reflect in the relationship they have with their medication.

Yeah. Like if you have given me this diagnosis of depression, then we kind of, we had to connect as human at some point and you saw me for who I was in that moment and said, I think you have depression. And this pill is like a little avatar for that conversation that I have to take an SSRI. So if you shouldn't have 

Margaret: to suffer with [00:27:00] them that much and that I think there's something that can get better.

I also think like a relationship, like if we think about how it. Impacts each of us, even not in like a therapy or health, even just like person to person, like that. We know that relationships change people's health outcomes. Like we know they're one of the like predictors of longevity and that placebo in that instance is like placebo probably is a whole heck of a lot because that's one of the things that I think comes up in the like chronic pain world or in psychiatry is like, Almost like this placebo count and so we're not saying that placebo also still isn't like important or a part of like in that even the concept of placebo is extremely complicated.

Like when I say 

Preston: placebo, I'm acknowledging the significance in the weight of placebo as an independent phenomenon. Yeah. And like you're saying, it gets equated to fake.

Margaret: And then [00:28:00] that rapport is something additional 

Preston: that also gets equated to fake 

Margaret: because I 

Preston: mean, placebo is incredibly powerful. And I think it's unsung. So if you do sham back surgery on someone that does wonders for their chronic pain. One of the most interesting effects I saw was in Parkinson's patients.

They took levodopa, carbidopa and placebo, and they were still able to measure increases in dopamine, the basal ganglia, the placebo group. 

Margaret: So 

Preston: the anticipation of the drug effect was able to change the neurotransmitters that were present in their brain. And I think a lot of. The neuropsychology of anticipation is related in these dopamine and pleasure pathways.

Yes. So, whether it's true for Parkinson's or other patients that anticipate a medication effect, it actually [00:29:00] does physically release dopamine, 

Margaret: which is 

Preston: the mechanism of many different drugs. Right. Sertraline is a dopamine reuptake inhibitor. Amphetamines disperse dopamine from the VMAT vesicles. 

Margaret: Mm hmm.

Preston: All of these things affect dopamine, but so does the anticipation of an effect. So if I give you a saltine and you think that it's going to take away your pain and the anticipation of that pain relief actually releases dopamine in your brain, you're, you're getting effectively a drug effect. 

Margaret: Right. 

Preston: And the same applies to having a therapeutic alliance with someone.

Right. Which I 

Margaret: think relates to like our episode last week, right? Like attachment, but it's like there were measurable differences on like the infant studies of how they felt. Related and attached and comforted that was measurable by like heart rate and stress responses. And so there's, I think there's, there's always, and it's in some ways we had to have done this in the history of all of this, but there's been these really like sort of rigid mind body.

Walls to say, like, pain is real. If it's this, if we can [00:30:00] look at an MRI and your back's doing this, even though now we know that's not true, that's not correlative 

Preston: or like, um, 

Margaret: real seizure, 

Preston: fake seizure. Yeah. Or like mental health and 

Margaret: everything else. Um, and I think one of the things that both you and I think and both have interest in is some of these places where it more explicitly crosses over and it's harder to.

delineate the neurons in someone's skull versus the neurons in the rest of their body. 

Preston: So, I mean, like fundamentally, I believe that we are our cortex. I exist as a consortium of matter and my thoughts, my emotions and my complexities are all at the whims of chemicals and the laws of physics. 

Margaret: Oh, we disagree on that then.

Preston: So yeah, and I think that's why I lean more into neurology. So why I, while I cannot use my understanding of chemicals to explain my behavior, I know at that microscopic level, the same [00:31:00] way, like I can't use. My understandings of zeros and ones and binary to explain how a program plays a video on my computer.

I still trust that at its core is just 

Margaret: electricity 

Preston: and matter and there's no reason for me to draw this arbitrary line between software and hardware in my computer. And I think that's how I viewed my mind. And so when we have this idea that. It's going to be on one side of the fence, the other side of the fence, the real side or the fake side, I get really frustrated with that and I see it just kind of as this continuum, like the seizure thing.

I have a hot take there. There's this search for real or fake seizure and I think I now I see we use a lot more as epileptic and non epileptic, which I prefer. And I think I was like, try to use that language with the patients because they'll be like, Oh, you know, it wasn't a real seizure that you had [00:32:00] and they're like, okay, well, I still had this episode.

And so you can say like, it was a non epileptic event, but you're still having something that's affecting you. We just don't know where it is on the continuum. And I think we're kind of like, where are this to like PNES, psychogenic, non epileptic seizures. Has a significantly increased risk for epilepsy and epilepsy has a significantly increased risk for PNES like it's kind of interesting.

So patients that have non epileptic seizures are more likely to have an epileptic seizure. So I asked a neuro resident one time, I was like, Hey, do you think an EEG is 100 percent sensitive for epilepsy? And she's like, well, if we see a seizure, we see a seizure. I was like, yeah, but do you think it's possible that like someone with PNES is having an epileptic event?

We just don't pick it up on our wires. And she was like, well, if it's, if it's not picked up on the wires and it's on epileptic event, and I was like, I get that. But like, do you think it has 100 percent sensitivity? Like, are we capturing every single epileptic event or are some getting left out and we're [00:33:00] classifying those as PNES?

Margaret: Yeah. 

Preston: And I think there, and because even within PNES, there's an entire spectrum. Right, right. Because there are some that. Physiologically make absolute, like are inconsistent with our understanding of the brain. Like, for example, if I have a partial seizure on one side and it crosses over. 

Margaret: Yeah. 

Preston: You can't have a dual partial seizure because that would imply both of your thalami are knocked out.

If both my thalami are occupied with uncompensated electrical activity, it is physiologically impossible for me to be conscious. So, so something like that, I think we can use evidence to say. We have 

Margaret: to ask like the question of. Is the science of all, like, do we have sharp, like a good enough microscope, basically?

Like, do we have the tools to measure? Is it not real? And I think in some ways there's comfort that we feel, um, in terms of like being able to pretend like modern medicine has all the like best and like most optimal, like [00:34:00] microscopes or tools to measure and that we can detect things. And I think that's something that we want to believe as people who went into this, hopefully to help people feel better a little bit.

And it's something that I think. Gets sold to people as an idea that is definitely true that like if your doctors would just do the right set of tests and that give you the right things, then you wouldn't feel this pain when the reality I think is that while there is medical gaslighting in a lot of different settings, and I won't deny that in the history of that, there's also a lot of places where we do not have good answers or good tools yet.

And I think That I think pain, I think unexplained pain, like we're getting better neuroscience, but we still don't really know. And it's like a really hard thing to acknowledge. I think after this break, I think we don't actually disagree on this part. I think what we disagree on is like the, like, how do we make sense of it in terms of like, what is the unexplainable?

And I think we go very different places that are maybe related. Um, But when we come back, we will talk about my hot [00:35:00] takes on that, as well as how our rapports play out. Rapports? Is that, is there a plural? 

Preston: Rapporti. 

Margaret: Rapporti, rapporti, rapportis, uh, how they play out differently in our different settings, because Yeah, I 

Preston: think, I think we've acknowledged that, okay, this thing is real.

It can change someone's brain chemistry, but this, this is a lot easier said than done. And I, unfortunately, I can't keep making those jokes, um, like I did in my OSCE. 

Margaret: What 

Preston: about tell you a 95 year old that it's not too late to go find someone

Welcome back to set the stage Margaret I want you to picture you're going into the emergency department. You just got a consult. 

Margaret: Okay, 

Preston: and this patient is an adolescent they're 15 and The ED provider is concerned about suicide ideation. 

Margaret: Mm hmm. 

Preston: So This can be like a challenging patient to develop rapport with [00:36:00] because you have like it's almost like a drive thru.

Margaret: Yeah interaction 

Preston: What are some techniques or tricks you use in those scenarios? 

Margaret: Well, I mean, I think one one thing I'm note here is that I'm Massachusetts and I'm in Boston. And so There has been a couple of settings where there's been a 15 year old in the adult emergency department, um, that have been challenging because they're not supposed to be there.

So I think the first thing I'm thinking when I approach is like, wow, and I think, you know, in Boston and everywhere in the country in the last few years, like, emergency departments have been overflowing and over overwhelmed and trying to provide care. And so my first thought when I'm going to see them in this setting would be like, And this would be true even if they weren't 15 is just like often they're going to be in a bed in the hallway because of capacity issues.

So how do I try and make this as not like as not scary as possible? How do I also think about how I'll interact with them in terms of [00:37:00] interacting with them and then having the parent be there versus like be away for part of it from like an adolescent interaction approach? Um, and how do I help them have like a, like, this is for this type of patient, like might be the first time they interact with a mental health professional and think about kind of.

Okay. How do I approach? How do I not kind of come up and just get straight to the point and be like, I heard this in front of parent, like, or like, I like immediately go, I heard 

Preston: some little birdie told me that you were suicidal. Right. You know, like that's not how you open it. Right. Um, even though that's like the whole premise of why you're going to see someone.

One trick I learned that I've been trying to apply is to start with the social history. So yeah, when I, when I go into the room, I'm like, Hey, I'm with the psychiatry team. You may, you may have an idea where, why I'm here, but before we talk about that stuff, I just kind of want to get to know you as a person.

So what's your name? Oh, Kyle. That's awesome. Kyle. Like, [00:38:00] where are you from? Nice. I have some family in Ohio. So, so tell me about how did you get all the way here from Ohio, you know, and that'd be kind of like. As we go through their life story, usually you find your way to the HPI, right? Yeah, like it, it becomes like relevant sooner than later, because I think as we kind of go through their childhood stuff was tough back then.

And now they're having some interpersonal struggles that derived from that. And then all of a sudden you're like. Now let's talk about today. 

Margaret: Yeah. 

Preston: What brings you in now? So I think I try to kind of almost like slide it in like as a conversation, have them like catch me up on what's been going on rather than starting with the HPI.

Oh, you were suicidal. Let's work backwards from there. And then asking you a bunch of bullet questions about your social history. 

Margaret: I feel like I think of it in some ways in the same way that we were taught in like medical school, how to do like a physical exam on a [00:39:00] baby where it's like, In PEDS, they're like, you need to start with, like, you need to kind of get the kid comfortable and then you have to kind of balance, like, upsetting the kid with, like, getting the information you need.

And so, like, you shouldn't, like, go and, like, walk into the room, immediately be a stranger and be like, okay, now I'm going to look in their ears, which is, like, the most kind of, like, ah thing, and, like, start with giving them the shot that they need at, like, a checkup. Like, I kind of think of the psychiatric.

Like exam the psychiatric encounter similarly where it's like, I mean, I think this is probably just good human, you know, behavior to is to not come in and be like, I'm going to do. The most upsetting part first and make it just really, let me open 

Preston: with the most invasive question. Let 

Margaret: me start there. 

Preston: Yeah.

Imagine this is the worst day of your life. Let's open with the most invasive question. 

Margaret: Yeah. 

Preston: The, so it's funny that you, you bring up that bed in the hallway scenario because [00:40:00] that happens a lot in my hospital too. We have a County hospital. We're often overflowed. And so. I often, I, I, this is one scenario where I try to use humor and I think I try to like judge the situation beforehand.

So if I see like they're a bit banterous or they're kind of like trying to make the most of a tough situation, I will kind of like lean in and acknowledge the absurdity. But I think I always at least want to acknowledge that, hey, you're in a hallway and not in a room. I think some people almost like pretend like, ah, everyone at our hospital gets great care.

Right. I, I will never say anything bad. And it's like, I didn't like during the hallway, man. Like you can acknowledge it. And like, yeah, it's, it's not like the best situation, but like a human being doesn't want to spend 36 hours stuck in a bed there. So, so I'll, I'll, I'll be like. Who did you have to pay to get this fancy bed?

And they're like, they're like, I know someone and then we'll kind of like, I'll make this [00:41:00] like hyperbolic joke that like, they have the king suite, you know, and I'm, and like, so when I'll, I'll, when I go to leave, I'll say something like, you know, I'll check and see if we have any openings in the parking lot and we'll see if we can upgrade you.

But right now, just stay here in the hallway. And they're like, don't worry, we won't go anywhere. And I think that Being able to laugh at the absurdity of like trying to do a neuro exam and a psychiatric interview while there's like nurses and crash carts pushing back and forth. Like it has to be something that she, that she would acknowledge.

Margaret: And I think, I think that acknowledgement too, is like such a big part that you're not going to just be like, Well, I'm here to get my information, sir. Like that acknowledgement. That's like, Hey, this is kind of cruddy is like a good foot to start off 

Preston: on. And it's funny that like saying this type of social history first or engaging them as a person.

I'm only thinking back to these rubrics. We use the trust and physician skill. It's like one of the questions, does my doctor care about me as a person that we try to measure? So the explicit, how do you show you care about someone as a person [00:42:00] is to ask the social history first to acknowledge their feelings, to validate the situation.

Margaret: I think there's also a part of it that it's also like, and this looks different in different situations, but that You care about what they care about, which isn't only like the social history. It's also being like, that's a, that's a portion of it. But I also feel like a portion of it is like the competence part of being like, no, you can trust me that I'm like, not going to like me and or with you, like, and not, and like, we're not, I'm not gonna make you talk for 90 minutes if you don't want to, but I'm still going to make sure I'm asking the important questions.

And sometimes that like as overemphasizes the only thing that matters, which I obviously don't agree with. But that, like, it doesn't feel like we're leading our patients down, like, an unknown hour of an invasive or question mark question, like, because I think there's also a sense sometimes of patients of, like, You're going to ask me all these things to try and cozy up to me and that, but I know I just get to the part that I know we have to talk about, which [00:43:00] is a balance.

Preston: So you have to recognize if they want, want you in the room or out of the room and like how fast to go from there. I think the other thing that's helpful too is in this mutual trust is that we ask all these invasive questions and then we're evasive with our answers. Real. I asked them all these invasive things.

And then they say, How long might I be in the hospital? And we're like, Oh, you know, that depends on a lot of constructs and everything depends on, and I don't have an idea. It just, it just all depends. And they're like, that tells me nothing, like absolutely nothing. And so that's really frustrating because someone's being very vulnerable with you and you're not reciprocating that.

So doubt in our little column of like, do they see me as a human? Do they care about me? Well, they don't care enough about me to not be evasive. Right. And they're expecting these answers. So. If I don't know the answer, one rapport trick that's actually helped me a ton is just saying, I don't know. 

Margaret: Yeah, just don't kick the cane around.

Preston: And, and it's like opening with that, like [00:44:00] after, like how long will it be in the hospital? I'll kind of look them dead in the eyes and say, the answer to that is, I don't know. But as soon as I find out, we'll talk about it and we'll, we'll go from there. And they're like, okay, thanks. And they'll say, thank you for being honest because 90 percent of the time you don't know.

Right. And the worst thing you can do is say, you'll be out of here tomorrow morning. Right. And then something else comes out and then they're like. The doctor promised me something else. And now you've completely shattered their trust in the system, but it's also not helpful to sit there and give a vague answer.

Like I remember, I remember one time, this is a different scenario, but we were in pre op and the patient goes, is it going to hurt when I wake up from surgery? And the surgeon couldn't give a yes or no answer. They were just like, you know, it just depends on a lot of factors. It can depend on bleeding. It depends on infection.

You know, surgeries can really depend on a lot of things. And the patient's like, yes or no. Like, is it like, yes, dude, it's going to hurt. When you wake up, there will be some we're cutting into your body. You can acknowledge that there will be some ounce of pain, like more than zero. Like, but the [00:45:00] surgeon maybe had this idea that like, if I tell him there'll be in any pain, like it's admitting fault or something like that.

So I like, and I've seen other providers in that scenario where they're like, yeah, it's gonna hurt. 

Margaret: Yeah. 

Preston: And it looks different for everyone. Wow. What a great succinct answer. Yes, I'm cutting into your body with a knife. There will be pain tomorrow and it's going to vary. A ton of pain that you can't handle.

That's not normal. A little bit of pain that's uncomfortable. Yeah, that's to be expected. That's the range you can get. I'm like, oh, wow. Now we're being real. Right. So that, so it's crazy how far you go by just. Being honest and then also extending out that like all of branch of I want you you as a human for you as a patient, 

Margaret: right?

Right. 

Preston: I think I think I emphasize that a lot in the ED scenario 

Margaret: Well, I think there's also part of it that goes into this and this is like a bigger conversation that we'll have to do an episode on at some point probably but one of there's interesting kind of studies on like [00:46:00] Kind of questionnaires on empathy and compassion and healthcare and what someone's capacity for that as a clinician looks like before they start med school while they're in med school.

And as they go through like residency and fellowship and how it declines, especially over med school. Um, so I, I, I think a part of this report conversation too, that we're kind of getting at from the sides is. Like, how does training impact our ability to be clinicians who build rapport and have capacity to do that?

And how does like the setting that you're in impact the bandwidth you have? Because empathy costs something. Like, empathy is not free. It, it requires mental space, right? It requires time, requires that you don't have to see 20 patients in the next hour. Um, not to be like, oh, poor clinicians, like blah, blah, blah.

But just to recognize that like, we also don't operate in this vacuum. And so, I think, I think it's this like really tough combination of things of like when there are parts of [00:47:00] us that maybe have this like idea of how we're going to be that like the big like kind of big man on campus, savior of our patients and do all these things and be really smart and right all the time and we need to work on that internally.

In the culture of medicine, and there's the part of how do we do better when we're exhausted? Um, and that, that, that impacts for poor as well. And I'm thinking of this in the ed setting just because that's where so much of like my call. And I think a lot of psychiatry residences call happens where you're like back to back patients.

You're the only psychiatrist in the hospital. You're on a 24 hour shift, whatever. 

Preston: Yeah, I find myself struggling with The, you know, thoughtful, supportive statements. 

Margaret: Yeah. 

Preston: Sometimes it's like three in the morning. All I can offer someone is like a summary statement 

Margaret: and 

Preston: I can't just be like this, this person I hoped I would be because I think everyone likes to picture themselves as this paragon of [00:48:00] compassion.

And I think I've kind of realized that sometimes I'm trying. I need to give the patient the best version of myself at this moment. And if that means I'm attempting to do all these things that I don't have the capacity to do this, it's doing them a disservice. And it's doing me a disservice. Like, and I think even in those scenarios, it's It's helpful.

Like it's not, not everything can turn into this beautiful psychodynamic therapy session. Sometimes we can be more to the point and acknowledge that like the context is going to change. So now let's say you have a little bit more time and my 

Margaret: favorite outpatient. 

Preston: Uh, yeah. 

Margaret: Um, 

Preston: so 

Margaret: because you just started outpatient and I am, I did a fourth year and in my outpatient chief life.

Okay. So I love this. I'm going to give you a clinical situation. Like you just gave me. So let's say this. Um, [00:49:00] it is 4 p. m. You have your last follow up of the day. It's been a very draining day so far. You're tired. Someone made you film podcast episodes the night before me. Uh, and you are just kind of, you know, you were on call over the weekend, blah, blah, blah.

You have your final, you have a follow up. This is the third time you're meeting the patient. You've already met them a couple of times. The last time was three months ago and they kind of, the, they didn't show up for a follow up. Um, the patient is an, a 50 year old male, uh, with PTSD, who, who has told you that he's not really interested in therapy and isn't sure that therapy works and is having a lot of.

Resistance around taking a medication slash is just not sure how much you trust the medication, which again, as an aside is sometimes fair, uh, and you're going to see him and you come in and [00:50:00] what kind of things do you think about and building rapport for this patient who you've not seen in a few months?

You've only had a couple visits with and who has some hesitancy about what what therapy or psychiatry can offer. 

Preston: So yeah, I feel like you beautifully described the V. A. Patient. And that's someone that I see a lot. Um, one, one thing I've found is that these guys have an acknowledgement of the burden that mental health has on them.

So maybe they're Vietnam veteran and they can't go to the botanical gardens with their family because of how bad they're, it exacerbates their PTSD, but also they have all the stigma around mental health. And I think it's because they equate it to almost like a moral failure. A lot of people from that kind of Gen X.

Um, baby boomer generation have that view of mental health. So I always try to like, avoid putting that label on them in any way. And I kind of let them use whatever language they want. 

Margaret: Yeah. 

Preston: If they just kind of want to call it stress, I'm not going to hamper on calling it [00:51:00] PTSD because like, I just get stressed out sometimes.

I got to handle my stress. I'm like, sounds good, man. How do we make you less stressed? Another thing that like I'll do is I kind of think about the. Body language they have 

Margaret: in 

Preston: their, in their approach to it. And I tried to mirror it. And it shows we're on the same page. So for example, a lot of guys from, from this demographic don't want to have this like open and vulnerable.

Let's talk about my emotions conversation. They don't want to have this open touchy feely conversation. They want to roll their sleeves up and treat it like any other problem in their woodshed. So. We'll kind of lean over, I'll rest my forearms on my thighs, kind of interlock my fingers, like I'm a football coach.

And they'll sit over like that too. And I'm kind of like, okay, what do we do about this? 

Margaret: You 

Preston: know, so we're both like, we're not, we're not doctor or patient anymore. We're just two bros leaning in, thinking about how we can make someone have less associative episodes at the botanical gardens. And so the other thing I'll try to do is.[00:52:00] 

They will say very negative things about the system, and I think some people are very afraid to acknowledge that in a reflection. So I had a patient like that. He was like, this hospital's dumb. I'm leaving, right? I wish I'm gonna leave right now. I'm, I ought to head out. You guys aren't helping me at all.

But this, the patient's still in the hospital, right? So. Their, their actions and their, their desires don't match there. So there's an ambivalence there. 

Margaret: Yeah. 

Preston: Right. So some people would be like, Oh, you know, like, I understand you're upset, which is not ideal to say, because I don't understand. I can never know where they're coming from, but you should stay.

So, so implying they're in contradiction, but really the ambivalence is kind of in the air. So I'll use like a dual side of reflection there. Yeah. Say the way you see it, this hospital is doing nothing for you. And it sounds like you should just walk out. And he's like, I do. And I was like, and another part of you feels different.

Margaret: Ooh, a little motivational interviewing. 

Preston: Yeah. And he'll be like, well, another part of you wants to figure out what the heck's going on with my [00:53:00] brain. And I'm like, and I do too. So, so by kind of like using this double sided reflection, especially these patients that have a lot of negative ideations around mental health, acknowledge that negative ideation first, and then acknowledge that.

If this patient who has PTSD, reluctant about mental health and hates all this stuff, is showing up to my office, they have ambivalence about it. And that ambivalence is somewhere. So I acknowledge the part, medications are stupid, you don't think they'll help. And yet, here you are in my office.

So even like, one thing I'll do is I'll lean in with, A party who thinks the medications are dumb, and then you can imply that another party who thinks otherwise, and you can let them fill in the blank. So that's, that's kind of my two pearls, I guess. I treat it collaboratively. I let them use whatever language they want to use.

Because I don't, I don't care if we call it PTSD. I don't care if we call it Magnolia [00:54:00] Syndrome. We could call it, like, gummy bear attack. I just want you, I just want you to experience your life in a way that you want to. 

Margaret: And 

Preston: if we do it collaboratively, that's fine. 

Margaret: Right. 

Preston: Right. So that's kind of how I approach like the, the VA type patient, the, um, and the only other thing I'll do sometimes is a place I'll disclose is I'll tell them about my military 

Margaret: experience.

Preston: So if they're Navy, Army, Air Force, I'll be like, I'm in the Air Force. And I think that's a unique disclosure that I try not to do too often unless someone is in the military, because there's an immediate moment of, Oh, you get it, right. And so sometimes I try to take advantage of that to say, like, Hey, I'm in the military now.

These walls can come down and we can collaborate a little bit more because there, there still is this almost like tacit wall between like someone who's [00:55:00] a civilian their whole life and someone who's like been in the armed forces 

Margaret: when I think it gets in this, like the, like two sidedness to the role that, I mean, in that situation that you play, but of like, You both, like a patient comes to us and kind of inherent in that is that we want things to change for them because they don't often come to us if they're like, my life's rocking, at least in psychiatry.

Right. They usually come. With, with something that they would like us to help, especially the patient that we're talking, kind of patient we're describing where they kind of have a lot of things they had to battle through to actually get to your office. Um, and then the question of like, how do you be yourself in interactions, which I think is like, anecdotally, a huge part of actually building rapport and.

Not take up too much space in the patient encounter, but also not leave something open that you actually don't feel comfortable sharing or talking about with someone who you [00:56:00] relate to in this way, for whatever reason, someone might, might feel comfortable or not. Um, so that it's, it's an odd relationship.

I think that's something we don't talk enough about in like medical school is like we talk about professionalism. It's like where the right thing and say the right thing. And you know where the right blazer or whatever. What we don't talk enough about is like how to actually like show up in a coherent way that is you and also at the same time, partly not you and it's like, how are we supposed to do this thing of rapport and build a relationship when we're, we're all kind of like languageless for this huge part of what we do in our, in healthcare?

Preston: Yeah, I think I was, I was trained to collect a history, but not how to be authentic. 

Margaret: Yeah. 

Preston: Right. So I'm armed with my battery of questions that I'll beat you for information like a pinata, but I don't know how to like show up as as a human being. Who is like half, half doctor, half me, [00:57:00] right? Some, some weird animal or if so, and, and the authentic version of Preston has mixed success.

So like I can do really well with some people. And then I also struggle a lot of different demographics, which is one of the beautiful things I think about psychiatry. So I was curious for you, what is your best demographic and what is your most challenging demographic to build rapport with? 

Margaret: This is always tough because it's like, I don't know if my patients, I mean, they can let, if any of them see this, they can let me know, but I think it's, part of it comes from like an understanding of an experience, like you're saying, right?

With like the patient knows it, but also, you know, it like, you know, the feeling of something. So I think I like naturally connect pretty well with like adolescent girls and like. Young adult women, women at like kind of different life transition points. Some of that is my experience [00:58:00] as a woman, but some of it is also like, I'm interested in how that story unfolds, right?

Like, there's like the part of understanding that comes from having lived something, but there's also the part that comes from like, I think separately, that's just like an interest. Like, I think the like neurobiology of eating disorders is really interesting. And how do we make sense of that? How do you make sense of why your stomach feels like that when you're starting like to have like nutritional recovery?

So to me, I think when there's a combination of like, I'm clinically interested in what's happening sort of scientifically and From a rapport level, like to me, those separate, those things aren't separate, um, and, but from a rapport level, then there's also the, like, I understand in some way what your day to day life would be like and what we're trying to move you towards and like, why you value what you value.

And I think it's really exciting to like, I don't know. I think it's a justice issue for me to like. Help like female identifying folks with [00:59:00] transition points related to body image related to like pregnancy, perinatal pain. And so I just like care a lot. And I think that's a huge story to talk to people about.

Preston: I think it's important to have that, the awareness of what your story is and how it intersects with other people. Because as. Didactically interested as I may be in eating disorders, I will never know what it's like to be a 13 year old girl in America and that's an experience that you have and like, like it's information that I'll never be privy to and I'll never like truly be able to understand that.

So, so as far as my ability to establish report, it's not going to be a road I'll be able to use. I'll have to kind of take a different route and so it's just naturally going to be more challenging. For me because of my pallet of life experiences, 

Margaret: I think that's the other thing. I'll just say about it It's [01:00:00] like I think a big part of it that we talked about is like empathy and having like similar pain experiences But I found at least especially in like outpatient or like longer term like patient doctor relationships it's also like that we have something about joy in common like that we both like love Taylor Swift or we both like Love a certain type of like food or a certain restaurant or whatever, anything small or big, but that that is a shared thing.

Um, so I feel like we talk a lot about the shared pain, but there's also a shared joy that I think really makes it easier to build something. 

Preston: I'm smiling because I'm in Pete's clinic this week and the amount of times I brought a fortnight with my patients.

I'm like, I'm like, are you build or no build? And he's like, I'm build, I'm pretty good. I'm like, Oh, I'm no build. I'm not very good at this stuff. 

Margaret: I don't know what any of that means, 

Preston: but it's, yeah, it's funny. Like even it, like [01:01:00] sharing joy with someone has done a lot for me and weirdly enough, video games has been a great way for me to build rapport with my patients.

Like, so I play this game called apex legends. And yeah, basically there's, there's like certain characters that you can play as they have different powers and some of them are associated with personality traits, I guess, like there's this character called octane. And like, if you play as octane, you're kind of like a toxic antagonistic person, or you play as this other person, you might be more supportive and helpful.

And so so many kids are playing apex legends at this clinic. I was at, I'd be like, I'd be like, Oh, what do you do for fun? Play video games? No. Nice. What games do you play? Apex. I'd be like, Who's your main? And they go octane. And I'm like, okay, I'm putting it on the note. He's a toxic octane main. And then they'd ask me, I'm like, I'm horizon.

They're like, Oh, sweaty horizon. I'm like, okay, well, we don't need to go into that. So it was [01:02:00] funny, like even just like sharing the joys of bonding experience, but then knowing enough about their. The, the games with them gave me insight into their personality, like we had this, like the, the fortnight situation build fortnight is technically really complicated on a controller.

And if you're trying to say someone has an intellectual disability, I don't know, dude, building is really challenging, like, you know what I mean? And so, uh, like maybe there's more volition contributing to this, like, poor school performance than we've considered, you know? 

Margaret: My version of this is when the Tortured Poets Department came out, I literally had multiple patients be like, can we spend the first 10 minutes during our sessions unpacking that and what I'm resonating with?

And I'm like, we sure can, girl, we sure can. 

Preston: Yeah, that's, I'm, I'm [01:03:00] so envious of that. That power. Cause I think, 

Margaret: well, you have it with that. Yeah, I do. I 

Preston: do. And, and so my, I think one of my more challenging demographics is like the young adolescent girl who, who I think we just, our Venn diagram and experiences doesn't overlap in the same way.

Margaret: Yeah. 

Preston: And, and I found males, 

Margaret: by the way, that's my struggle demographic. 

Preston: Yeah. I mean, you have a lot in common with the Vietnam veteran. We be 

Margaret: vibing. We be vibing. I bring out the Midwestern then though. 

Preston: Yeah, it's interesting. So like I, I grew up around all sisters. So I like appeal to that part of my identity when I go in and then I can kind of like engage with them more.

So I don't, I don't get to come out guns blazing fortnight Preston, but I can still have a pretty successful interaction and just think about like, okay, what in me has this overlap of experience? And it's usually a lot more than you think. Um, so that that's helpful when you give an, um, a validation or an affirmation.

Preston. How do you [01:04:00] think about offering those to patients? 

Margaret: Um, oh, it's such a big question. I, I What do you mean? 

Preston: So I, I guess what I'm getting at is some people I've noticed almost like refuse to praise patients. Oh. And they'll say, you took your medicines. That's great. Oh, that's awesome. Oh, this, that. So what they're complimenting is like the existence of the phenomenon rather than you're doing great.

Margaret: Yeah. 

Preston: Yeah. Hey. Thank you for showing up. So, so I was just curious how you phrase it because one thing I've noticed is the how you direct the affirmation makes a big difference. So when you're trying to establish a good relationship with someone, you want to praise them with direct language, but then use more passive language and describe it like negative things.

So I had this attending that work with who would say, like, you failed to take your medication. Why you got to say it like that? Like [01:05:00] they're already on the defensive. Right. And so, so You know, there are things that like we're all responsible for our actions, but how you frame it makes it seem more or less accusatory.

So you could say like, okay, instead of that, you can say, well, what made you want to punch the nurse? 

Margaret: Yeah. Yeah. 

Preston: Rather than why did you, why did you assault this person? You know? So if you use more passive language, then you can kind of. Be less on the attack when you're asking about negative behaviors, and then you can praise them and be like, you did a good job calming down or redirecting.

So 

Margaret: yeah, I think it's kind 

Preston: of how I try to approach that language. 

Margaret: It's interesting because I think like last year I was mainly like outpatient and like then call like in an emergency department setting where you like, I don't really know the patients and the emergency department setting except for the one time interaction.

Um, and then. This year I'm mostly outpatient and some like working in a partial setting and I say that because I, I think my style, because I do think like personality comes into this, I really think [01:06:00] that attention, like I'm not like, you know, Mary Oliver and Simone Vale, both are, you know, poets and philosophers who talk about like attention being the beginning of devotion and attention being the beginning.

And attention, meaning like actually really paying attention and noticing details. So I think I'm, I affirm my patients, especially the ones who I know and I'm working with by I'm not someone who's going to like shower it necessarily on them because I want Not that I'm not saying you do that, but I'm just saying, like, my approach is like, I want to wait until I feel like I know you and I know what we're talking about, and I feel like I can tell you something that I've really picked up on that has some depth and that I think matters to what we're 

Preston: talking about.

I think that's a great point because it can be disingenuous when you're just offering praise. Yeah. 

Margaret: And I think especially if you think about, like, the history of psychiatry, both in one individual's history of getting treatment and in the history of [01:07:00] our field in general. Is that there is a lot of like paternalism and opacity instead of transparency.

And so I always really want my patients to know that if I say something, I mean it across the board. Um, and so I think I'm a little slower, but I, because I want, I want to, my like best friend from high school always says that I have a really like, can't like uncanny ability to make people cry with affirmation, but that like, I really want to, it's not even that I want to say something that matters for my own sake, as much as like.

I want for them to not put me in the category as like, Oh, you're someone who says things because you think it'll make me feel better. 

Preston: Yeah. You, you don't view this comment as transactional and that I'm giving you something like prescribing you a compliment. Yeah. It's, I think, you know, from, from like the drive by joke fist bump in the ed to kind of this.

[01:08:00] Longitudinal relationship where you can say something profound and have someone come to its realization. And to the point where they're brought to tears, it's kind of the range of affirmations we have to work with. And it's like, okay, do I want to, do I want to go for my like super complex, hard double tuck backflip move, or are we just going to do a couple of front handstrings and a cartwheel today?

Margaret: We're going to like illusion twist situation. 

Preston: Yeah. As a rule for myself, I guess, and. I think I'm guilty of this a little bit. And maybe as an intern, as a PGY2, I can view the hospital setting almost as like a performance space where I have to, especially in the ED hallway bed, it's like you're putting on a show.

Margaret: Yeah. 

Preston: And I'm like, okay, I need to like get my routine down. And what is helpful about that is you can kind of protect your emotions a little bit [01:09:00] because you know, it's almost like character that you're getting into. You can get information well and you can have an amicable interaction and also you sacrifice the authenticity that you're describing and like having this powerful connection with someone and then being able to offer those kind of affirmations.

And it's a balance 

Margaret: There's this quote by Van Gogh that's like, you have to learn the rules like a pro so you can break them like an artist. And I will say, like, I don't feel like I felt like myself in my clinical interactions until I was like, ending third year. Like, I, not that that's like the path for everyone, but I feel like Only now am I starting to feel like I know, not even know enough, but have done enough reps that there's some space for me to come back into it, you know what I mean?

Because I feel like it's hard because you're like also trying to do this role for the first time that is like you and the patient, you and the, like the staff, you and the like other [01:10:00] person who's sitting over there, who's also your patient who you haven't seen yet. And that's like, It's hard to do, try and do that and be yourself similar to like trying to sound like yourself when you're like learning a language for the first time.

Preston: So I hope that I'll kind of be able to find myself as I can trust my interactions. And I think it's easier to do that when you don't have someone observing all of your clinical encounters. I think I'm used to maybe as a performance. because I'm used to an intern coming over me and watching me. Mm-hmm

And I'm not just, I'm just performing for the patient. I'm performing for my grade. 

Margaret: Mm-hmm . Or 

Preston: when I'm the intern, I'm going with the PGY two, but now I'm the PGY two. 

Margaret: Yeah. 

Preston: Now I'm now I'm the one going by myself. I can think like, okay, how does Preston want to be the psychiatrist now? Do you do, 

Margaret: does your outpatient now, like, are you by yourself as a two?

Preston: Yeah. Okay. So in my clinic I am interest too. Yeah. So it's. It is interesting to kind of like see my style to come out a little bit [01:11:00] and 

Margaret: I remember like starting out patient I was like what is like I was like, yeah independence finally I'm gonna do something and feel like the doctor and then like immediately being like what now who am I?

Where is the adult in the room? 

Preston: Like a little too open ended. 

Margaret: Yes. 

Preston: So as we kind of come to a close, do you have any other? Thoughts or tricks you use for either building rapport or that, or did you think it's like more important to focus on for someone who's trying to capture this nebulous topic, but also important factor that modifies care.

Margaret: I think one of the most important things that I was ever told during, like when I was a med student by one of my like psychiatry mentors was that in psychiatry. And I think this is true larger than [01:12:00] psychiatry, but that like. Your personhood and who you are. Is what is similar to your stethoscope or your like x ray.

It's like a huge tool and maybe one of one of the most important tools in how you treat patients and psychiatrists. I think from what we talked about beginning with rapport that that's probably true to some extent as well in other parts of health care. Um, And, and that who you are, I don't think there's any one personality type or set of strengths and weaknesses that is like the ideal doctor.

Um, I think so much of getting into medicine is about performing well and, and kind of putting on a performance of perfection to get through all the hoops. And that leaves a lot of us, like, scared and anxious and unsure, and it's also important work, and so we're scared for those reasons. But that this process of unfolding, that like any personality can fit.

Because there's patients with any get different personality or kind of like [01:13:00] style 

Preston: and anyone can fit with anyone I think they all don't work, but it has a potential. 

Margaret: Yeah, 

Preston: I guess I see All right, I draw the connection to like kung fu panda We're like whether are you using like Tigris style or crane style or snake style?

We all have our personality organization. We all have our techniques We all have our strengths to all of our weaknesses, but whatever variation of kung fu you use You can still go to battle or go perform and somewhere 

Margaret: it's about practice and eventually like finding the one that fits and is sustainable.

Preston: Yeah. So, so if you're an expert at crane technique, cause you practice it every day, that master might do better than someone who only barely tries to do mantis or something. You're like taking this Kung 

Margaret: Fu Panda metaphor to 

Preston: the end. I'm beating it to death. 

Margaret: It's that piñata with the questions that you mentioned earlier.[01:14:00] 

Preston: I think that. Some people will fall. They'll count themselves out. They'll be like, yeah, Tai Lung. He's going to kill me because I don't know the wishy finger hold. And so if you're not familiar with Kung Fu Panda, the wishy finger hold is, uh, a secret technique used to take out Tai Lung, possibly a future episode.

Yeah, we'll go into it. But the point is like, Just because that demographic isn't your key demographic. 

Margaret: Mm hmm. 

Preston: So if you walk in the room, you see an older veteran to say like, oh, I'm not gonna, I already know I won't connect with them. 

Margaret: Mm hmm. 

Preston: And if you have that thought, then that for sure is what's gonna happen.

Right. But if you say like, okay, this, like, this is not gonna be. Easy for me, like these other patients are, but then you, because you're putting effort into it, you can end up having a very strong and like powerful, um, clinical relationship just, and I think it starts with acknowledging that [01:15:00] it is a difference for you.

So, so, so it's not helpful to be like, I'm equally good with all patients. Right, right. That's a lot. I know that's not true. 

Margaret: Yeah, that's a lot. Yeah, no, I think more for us to come on on this, like, topic, because I think there's so much underneath the hood. Um, but, you know, I feel like Preston, we built a little bit better rapport between us during this episode.

Preston: Yeah, I do. I feel like I got to know you as a person. Someone who cares a lot about having an important affirmation. I think I trust you to make decisions for me. So you're scoring pretty well on my trust in physician scale. 

Margaret: Does that mean that you're gonna, uh, 

Preston: take my blood 

Margaret: pressure meds? 

Preston: Yeah, I'll adhere to my medications now.

What do we want to talk about next week? 

Margaret: Let us know what you guys want us to talk about. We have some ideas, but not all of our ideas are great. So please weigh in and let us [01:16:00] know. 

Preston: Most of my ideas are great. Remains to be seen. But I would like to hear your thoughts regardless. I just like hearing your thoughts.

Margaret: You can come build rapport with us on Instagram or TikTok, uh, through the human content podcast family, which is at human content pods. You can contact us directly at the howtobepatientpod. com website. 

Preston: So I think this is great because next time, um, I'm seeing if I can get one of my CBT professors. So rapport is one thing.

But then, like, how do we apply it? Yeah. How do we apply whatever modality? And I think one thing that I struggle a lot getting reps in is things like CBT or motivational interviewing, because it's so easy to be on a paper, but hard to apply in person. Yeah. So I think next time that's something we can kind of discuss and maybe practice a little bit.

How do you understand motivational interviewing and apply it in these almost like chess checkers style conversations? 

Margaret: Yeah. 

Preston: So this is a new show and I'm doing [01:17:00] my best, but I'm not perfect. And that means that I would like some feedback. So whether you like something, if you didn't like something, if you think I should do everything the same, I probably won't still do it the same, but if you think I should, let me know, because I just kind of want to understand how you're feeling when you're listening to this kind of stuff.

And if you, if you write something interesting, there's a good chance that we'll take it into account and we'll kind of make an episode about it or discuss it next time. So anyways, thank you for listening. And if you want to find us. On YouTube, you can find my channel at it's Presro, or you can follow me on Tik Tok.

I'll probably be talking about it there too. Thanks again for listening. We're your hosts, Preston and Margaret. Our executive producers are me, Preston, and also Margaret Duncan, Will Flannery, Kristen Flannery, Aaron Corny, Rob Goldman, and Shanti Brooke. Our editor and engineer is Tracy Barnett, and our music is by Omar Benzvi.

Margaret: To learn about our program, disclaimer and ethics policy submission verification in licensing terms and our HIPAA release terms. Go to How to be patient pod.com or reach [01:18:00] out to us at how to be patient@humancontent.com with any questions or concerns. 

Preston: How to be patient is a human content production.