On this episode we hear an attending family physician’s perspective on healthcare from Dr. Deborah Gilboa. Dr. G (as she is known) is a member of Generation X. She and host Rob Oliver became acquainted when she was in medical school at the University of Pittsburgh. During her interview on the Perspectives on Healthcare Podcast she shared some of her insights about resilience. Dr. G is based in Pittsburgh where she started a Federally Qualified Health Center.
Here are 3 things that stood out to me as Dr. Deborah Gilboa shared an attending family physician’s perspective on healthcare:
· A Family Physician can see kids, their parents, their grandparents and sometimes even their great-grandparents
· The difference between a specialist mentality and a generalist mentality
· Medical professionals can improve the quality of healthcare by simply asking patients, “How do you want me to address you?”
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Here is the transcript of Deborah Gilboa: An Attending Family Physician’s Perspective on Healthcare:
Rob Oliver: Thank you for joining me today. Today, I have a friend of mine that I met over 20 years ago. We we met through some very cool circumstances. She was spearheading a disabilities studies program through the through the Pitt Medical School. Anyway, she was doing great things 20 years ago, and she is still doing great things. Her name is Deborah Gilboa. She joins me. She is a member of Generation X. She is from here in Pittsburgh, Pennsylvania. She is a family physician and an overall wonderful person. Dr. G, welcome to the show.
Deborah Gilboa: Thanks so much. That’s, like the best intro ever.
Rob Oliver: You know what? It’s fun to have all kinds of different people on, but when you have people on that are that, you know, and that are just good people, it makes it even more enjoyable. Here we go. We start right off the bat. Tell me about yourself and your role in health care.
Deborah Gilboa: So I am an attending family Doc, like you said. And for people who aren’t totally clear, a family doctor is a board certified physician. It’s not so much anymore that you can be a general practitioner. When my parents grew up, they had their GP that’s my dad called it their general practitioner. And those are folks who’ve gone to medical school and usually spent one year in turning in a hospital. And then they just opened an office, hung out, they’re shingle, and that’s no longer an option for doctors. It hasn’t been for about 30 years. You’ve got to do a full residency, get bored certified in something. So I got born certified in family medicine, which means I can see everybody. I see newborns in the hospital a day after they were born, or sometimes an hour after they were born. I know how to deliver babies, and I take care of people through end of life care in there, hopefully 90s and 100s. And the reason that I think it’s so cool is that often in my practice, I see kids and their parents and their grandparents, and occasionally they’re great grandparents.
Rob Oliver: Yeah. I had a family physician on Dr. Parks, and he said the challenge of being a family physician is that you have to have such a breadth of knowledge that it’s hard to keep a handle on. What’s your reaction to that concept?
Deborah Gilboa: I teach medical students in the office every week, and I always tell them that when they’re trying to figure out what field they want to go into, they first have to figure out if they are a generalist kind of person or a specialist kind of person. One of my best professors in residency, his roommate in Med school became an ophthalmologist, but not just an ophthalmologist who focuses on the eyeball and three inches of nerves, but a front of eye specialist. So really, like, 2 mm of geography and every possible thing that can happen within that area. That is a specialist personality, somebody who wants to know absolutely everything about something. Then you’ve got a Sesame Street generation folks, and we’d like things to change. Every 90 seconds. We want to see Big Bird in one room and then come into another room and have Ello and another room and talk to Maria in Spanish. When you’re in that situation, when you’re more of a generalist personality, you want to know something about everything. And that’s definitely who I am. I don’t need to know absolutely everything. I need to know where to find science based, evidence based, reputable, reliable information about anything pretty quickly. And I need to know what I don’t know so that I ask you questions.
Rob Oliver: I believe that we’re kindred spirit and that desire to have a broad range of knowledge. Sometimes it’s not a real deep depth of knowledge over the breath, but knowing where to get the information is very important. What does quality health care mean to you?
Deborah Gilboa: Quality health care, to me, is really the kind of health care that I get to practice where I work, meaning I am not just allowed but expected at my health center to dig deep and to be persistent and to recognize my patients expertise and my own expertise and figure out how to marry those.
Rob Oliver: Okay, you said you’re recognizing your patient expertise. Tell me more about that concept if you can.
Deborah Gilboa: Absolutely. When I see a patient, they come to me for my expert opinion. And I know that sounds terribly immodest, but honestly, if you’re going to do eleven years of training, you better grow an expert opinion that’s based in a lot of knowledge and a constant learning. So they come to me for my expert opinion. I should be an expert on diagnosis and the body and our minds and how they work and what good questioning sounds like and being a really good listener and how to put all those puzzles together and what test to order and what medicines are available. But you are an expert on you. You are an expert in your history. You’re an expert on what does and doesn’t work for you. You’re probably an expert in whatever diseases or experiences you’ve gone through far more than I could ever be. And you bring a perspective and an education that I couldn’t have. So once I recognized have both the humility and the courage to help you recognize your expertise in your own life experience. Then you know that I’m listening to you and we’re much, much more likely to come to a correct understanding what’s happening and put together a plan that works for you. Then if I impose the little I know of your particular diagnosis on you, especially because what I know of your particular diagnosis is based on other people’s experience of that illness or that injury or that state, whereas your experience is based on your own life with that and it’s more accurate to you.
Rob Oliver: It is so funny to hear you. It’s not just funny, but it is fantastic to hear you say that. Okay. I do. In some of my speaking, I do a presentation for medical professionals, and I call it Robilogy 101 and the idea is I can teach you a course about me because I have the expertise in me, and that really fits in with exactly what you’re saying. You have you have an advanced degree in medicine, you’ve got the research, you’ve got the understanding, but without pairing those together… It’s very powerful concept. Can you give me an example of quality health care?
Deborah Gilboa: Yeah. So I’ll give you two. One is harder for most health care providers to do. My health center allows for home visits, and that’s just not financially reasonable or practical in most health centers, but I would encourage anybody who’s listening who could incorporate it into their practice that it does save you a ton of time on the back end. In my practice, everybody in our practice does house home visits for different reasons. For example, in our practice, our medical director said Geriatrician, and she goes to her patients that either can’t or won’t come into the office. And she considers that really valuable use of her time. And it really is for myself. I go when I don’t know what I don’t know about what’s going on with that patient. So when we’re really struggling to figure out how to make something better or why something is happening, I found in my I just got a certificate in the mail last week from the American Academy of Family Physicians, taking me for 25 years of membership. And I think I had the moment that a lot of people have when they get their ARP membership that I was like, oh, wow. Yeah. I guess right. In any case, in that time of practice, I’ve had a bunch of times where what I knew and what I really heard the patient telling me it just didn’t match. So I’m seeing a little girl in my practice who had asthma, and she had what we call mild, persistent asthma. She has it on the regular not only when she gets ill or when she exercises, but but it shouldn’t have been very bad. And she was ending up in the emergency room a couple of times a month. She wasn’t getting admitted, but they had to treat her. It wasn’t getting better at home. And they come in for their poster visit. They came in regularly for their visits. We talked about the medicines. Mom told me what medicines the kiddo was taking. It Max, what I thought she should be taking and what I heard and what the docs in the ear heard and what her imaging showed and her pulmonary function test showed. And yet they were still landing in the emergency Department a couple of times a month. So I asked if I could come over and she said, yes. And I got to the house. And this mom who had four kids under six, I saw her before my patients. So I was there at 7: 30 in the morning, which if you’ve ever had kids that age, you know, is already 2 hours into your day. And I got there and she was dressed beautiful. I mean, really like she was going out for a very fancy evening. But the house was a disaster. It sort of showed me that she was trying to show me that she did her best to get ready for this visit in a way that she knew it was important to her. But her house felt beyond her control. Her home was a lot of noise and a lot of cats and a lot of piles of things everywhere. And as I walked in, the girl that I was there to see who was just under six was waiting with her. But the three boys who were all four and under were back in the kitchen, and she heard some yelling, and she invited me back. And we went back. And they had dumped a big a big olive oil container out on the kitchen floor. And we’re having an ice skating time of their lives. And so as we were. And so her daughter and I walked back to her living room area so I could sit down and talk to her. And I noticed that the machine that she was meant to be using for her twice a day preventive breathing treatments was in a corner on top of some books. And then under a whole stack of magazines with dust. And I looked at it. And I looked at the mom and she said, no, I know that’s what she uses, but she doesn’t want to sit. It takes 25 minutes to do that. She said she doesn’t want to sit for that long unless I sit with her. But if I sit with her, you see what happens with my younger sons. And I just I don’t know what to do. So we talked it out. And her daughter loves to draw. So we found a coloring book in the house and said, okay, you get to use this coloring book. This is a really special coloring book, and it’s got some beautiful pictures. And you get to pick whichever one you want to color. You can only color it while you’re doing your treatment. You’re going to see me in two weeks, where you bring me 14 beautiful pictures. And her mom even said, and if you do that, then we’ll go to the dollar store after that visit and pick out a new can. Sure. And she was in. And it wasn’t just that strategy. It was that conversation. It was that I get it. And I could say to that, Mom’s totally get it. I also have four kids pretty close together, so I was genuinely able to say, oh, yeah, it is impossible to sit with one child 25 minutes twice a day. But I hadn’t thought to ask about those details when we were in my office and when I get to the house, it became instantly obvious that there was some sort of logistic barrier here. Child is now much older years and years older and has never been in the hospital again for asthma because it wasn’t her asthma. That was that bad. It was just trying to figure out the mechanics of getting her what she needed while the other kids got what they need.
Rob Oliver: Yeah. Especially when you meet people in their home, you’re meeting them on their turf and you get a glimpse into their life and what’s really going on with them.
Deborah Gilboa: And it can make people feel really vulnerable and you have to be incredibly respectful. So I’ll give you another very small example. I in my practice called every single person 18 and over by some sort of honorific and their last name, and I’m pretty stubborn about it. I have some patients who’ve been seeing me for a decade and a half or more and they say, Please call me by my first name, and I try to remember because that’s their preference. But I quit on purpose because there’s so much of a power differential. When a patient walks in the room, they are the seeker and the provider is the giver and the bestower. And that power differential isn’t good for anybody’s health. It’s not good for my health to put that much pressure on me, right where I’m above you and I see all and now all. And also it’s a lie. I don’t see all I don’t know all. So everything I can do to equal out that power differential. I also don’t wear a white coat. I can get away with it because I see kids, and so everybody knows it’s not great to wear a white coat when you see kids, but I really think if I’m dressed professionally, whether that’s in scrubs or dressed nicely and I have a stethoscope around my neck, people know who I am and what I do. I don’t need too many trappings, and those trappings really often make patients feel less than such an interesting realization and in a practical way to keep everybody in some ways on the same level and not struggling with the power dynamic.
Rob Oliver: What do you wish that people understood about your role in health care? Did I just ask you that you did not?
Deborah Gilboa: Okay. I see why. Maybe it feels like I already answered it, but I don’t think I did. What I wish people understood is that well, it is, in part what I did already say that I am an expert opinion. I’m not the decision maker. The buck doesn’t stop with me. And and I really mean this in the most resilient way. I will fail with everyone of my patients. Everybody dies. So there is a combination between quantity, which I’m all about and quality of life and the work that I do outside my health center is all about helping people have the skills they need to get from getting better to actually having a feeling of well being. And it turns out that that gap is filled in by resilience. And resilience is not just grid or your ability to power through a difficult situation and not lose it. Resilience is your ability to navigate, change and come through the kind of person you want to be. And what I wish people understood is that my goal. My job, as I see it, is to help people navigate the changes that their circumstances and their lives and their bodies and their genetics and their environment put them through and help them come through. It the kind of person they want to be.
Rob Oliver: A very, very powerful statement. What excites you about the future of healthcare?
Deborah Gilboa: Medical students and nurse practitioner students and PA students every time I work with a student. And I really do believe that we were already seeing this shift when I was in medical school 20 years ago, 21 years ago. But now almost no one is going into medicine because it is a financially secure career. They’re not going into it to make money, punch a time card, be rich, right? That’s just almost in the 80s. That was a lot of people’s motivation. I’m not saying there was somebody with a calling and that people didn’t know it would be hard or hear about people. But there was this idea that you should expect a lot of fiscal well being on the flip side, and that’s been pretty much debunked. Right. So we know that the amount of debt that you rack up compared to the amount of money that you make, it does not turn into new cars and fancy vacations all the time. And as much as I think that the way we pay for medical training is broken, and the way we pay for health care is broken, that’s a different topic. What excites me is that we do still have tons of people going into this career as a first or second or third career, saying, I want to help people be as well as they can.
Rob Oliver: I think that you really hit on a key there. It’s the difference between saying, I want to make a lot of money or the difference in saying, I want to help people. I want to make a difference in people’s lives because really, I think it flips it around because if it’s about me making a lot of money, then I go into this career for me. If it’s about me helping people, I’m going into this career for the people that are coming into the office. If that makes any sense, what is one thing medical professionals can start doing today to improve the quality of healthcare?
Deborah Gilboa: They could start by walking into the room with their patients and saying, how would you like me to address you?
Rob Oliver: Wow. Okay. Tell me more about how that fits in. It’s a super simple, super practical. What does that do in your professional opinion?
Deborah Gilboa: In my opinion, and I’ll use a really medical term. It defibrillate the relationship right from the start. It shocks it into a new rhythm. I’m expecting to as a patient, I’m expecting to have to fight to tell you my story. I’m expecting to have to advocate for myself, maybe against you, that you’re going to be a barrier to what I think I need. So if I start off by asking you something non judgmental that you know the answer to that, you don’t have to dig real deep for what would you like to be called? And I establish myself as someone who is asking your consent for something that is really important to us. How we’re referred to then I am approaching you as a knowledgeable adult, but I am approaching you as a peer.
Rob Oliver: It’s interesting. There was a a training video done several years ago. I say several. It was a lot, a number of years ago about, like, the Ten Commandments of dealing with people with disabilities. And I think in there one of the things was keeping consistency about how you address everyone, which you mentioned already. So when you have someone with an intellectual disability who comes in and even though they’re 35 years old, everybody refers to them as Jimmy and not as Mr. Smith. If that makes any sense, where you’re saying, what’s your preference? How do we keep this on? How do we share this? Make this a place where you feel comfortable and empowered and you’re being referred to in a way that makes you feel good about yourself. Listen, Dr. G, thank you so much for being here. I really I appreciate your perspective on health care.