Episode 6: The 3 E’s of the New Healthcare Relationship

Dr. Justin Smith, a.k.a. @TheDocSmitty, has totally reimagined the doctor’s ability to provide relevant, vetted health information to his patients and their families. He uses digital health – particularly social media and a patient portal – to point families to information that answers their questions and comforts them during stressful times. Like posting videos on Instagram for baby well visits so parents know what he’ll ask when they bring children in for check-ups at 2 months, 3 months, 4 months, etc. At every stage, Dr. Smith uses digital health to focus on the 3 E’s that patients and families want in a healthcare encounter – Engagement, Efficiency, and Empathy.

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Full Transcript

Announcer: It’s time to think differently about healthcare, but how do we keep up? The days of yesterday’s medicine are long gone, and we’re left trying to figure out where to go from here. With all the talk about politics and technology, it can be easy to forget that healthcare is still all about humans, and many of those humans have unbelievable stories to tell.

Here, we leave the policy debates to the other guys and focus instead on the people and ideas that are changing the way we address our health. It’s time to navigate the new landscape of healthcare together, and here’s some amazing stories along the way. Ready for a breath of fresh air? It’s time for your paradigm shift.

Michael: Welcome to the “Paradigm Shift of Healthcare,” and thank you for listening. I’m Michael Roberts with co-hosts, Jared Johnson and Scott Zeitzer. On today’s episode, we’re talking to Dr. Justin Smith, a pediatrician and the Medical Advisor for Digital Health for Cook Children’s in Fort Worth, Texas. You know him as the “Doc Smitty” on Twitter and Facebook where he has active communities, engages regularly with patients and clinicians. Hi, Dr. Smith, and welcome to the show.

Dr. Smith: Yeah, thanks for having me. I’m excited to be here.

Jared: Hey, Dr. Smith, this is Jared. I’m just glad and thrilled to really reconnect with you. It’s been a few years. You and I have known each other for a little while. I’ve even had you as a podcast guest previously, and I’m excited to really circle back with you to see how things have been going. There were a lot of things going on early on years ago with a vision that you’d had for Digital Health.

And really as we bring that into focus for this program, for Paradigm Shift, we’ve been talking about shifting mindsets. You know, how people are literally changing the way they think about healthcare, and there’s a lot of different ways that you have addressed that yourself. But I’ll just reiterate to our listeners just how…I mean, there’s no other word for it. I just think it’s cool. The work you’re doing, the efforts you’re putting into really changing the face of care and using technology to do it and recognizing that there are ways to successfully engage with patients online.

So those are some of the things that we’re gonna jump into today with you. But one of those very first things that I’ve always associated you with is being able to successfully implement and use digital health with your care model itself. And maybe that’s a good place to start because as we talk about, you know, like I said, how people really are thinking about healthcare differently, digital and technology are really things that, in the past, have been divisive almost in the clinical community and with patients as we try to figure out what its proper role is. So, I’m curious, you know, just first and foremost, and maybe this is just indicative of your philosophy itself, I’m curious what role you think the digital health plays in improving patient care?

Dr. Smith: Yeah, I mean I think, you know, as a pediatrician, it’s one of those things where I think if you…I want to engage really at this point now, I’m looking at Gen Z parents, you know. I mean, I’m really past… When I first started, it was really trying to figure out how to engage with millennial parents, but now it’s really that next generation. And I don’t think that I really have the luxury not to figure out how to use digital health because that’s critical to my new parents and what’s important to them.

They’ve grown up digital natives. It’s just the part of their lives. So I think it became just something that I saw as a need, and it’s only growing more as a need. I think the role it plays in digital health… I think we talked a few years ago, but it’s interesting that over time, I’ve gotten a little bit more structured in the way I think about it. And so I’ve really kind of figured that in my practice, my digital health engagement with my patients really fits in three different stages. And so I look at it from what I call a pre-encounter stage, an encounter stage, and then post-encounter stage.

And so I’m trying to engage in different ways with parents along that spectrum in a way that I find keeps them engaged with me, even when they’re not here in the office. Because that encounter stage is so brief relative to the rest of their child’s health journey, whether they be healthy and are just needing guidance along the way, or whether they’re sick and need more support.

Michael: Absolutely. So, this is Michael. My daughter has a condition where we’re back seeing our pediatrician on a very regular basis. And so one of the things that we have to deal with quite a bit is that in between, is that, “Hey, we’ve already seen the doctor, and we’ve had that initial conversation, but what are we gonna do when this next question comes up? How are we gonna handle it? How are we gonna talk to the right nurse, get in touch with the right people in order to get our questions answered in between?” So I love that you’re thinking of it that way.

Dr. Smith: Yeah, and I mean that’s so many different ways like you can…if I, as a pediatrician, lay off the expectation for, “Hey, here’s what’s going on, here’s what I expect to get better. But if it doesn’t, I want you to message me.” Or, “Hey, we’re gonna treat this rash, but if you don’t think it’s improving, just shoot me some pictures in a couple of weeks, and we’ll make an adjustment.”

Even if the family does get better, it does follow the expected course, just having that peace of mind that, “Oh, it’s just as easy as sending him a message if things don’t get better,” is the game-changer for that parent. They’re not having to go home worried about what that next engagement is gonna look like when or if things don’t get better.

Scott: Doc, just curious. You said you broke it down into three phases, pre-meeting, during the meeting, and then of course post-meeting. So from a pre-meeting, what kind of expectations are you trying to set? What are you trying to get to the patient and family and from the patient and family?

Dr. Smith: And so for that, there’s a couple of different things I do. My biggest thing, from a pre-encounter perspective, is engagement via digital health and…I mean, engagement via social media really more specifically. And so I am super active on Facebook and Instagram or primarily where my patients follow me. I’m not directly engaged with them there so much. But for instance, on my Instagram account, I have summary videos for each checkup.

So, I’m up to, now I’ve done the nine-month checkup, and I have families who have followed along with those. And so before they come in for their two-month checkup, they’ll go and watch the two-month checkup video on my Instagram highlights, and that gives them the high level of what I would normally cover in two months. That way if they have the basic questions, they can get those answered. They know the questions I’m gonna be asking them, so they’re really efficient in responding to my questions when they’re in the office.

You know, when they do come into the encounter world, we can hit that next step and that next level of questioning, so I’m not having to ask them the basic questions that I have to ask everybody else who hasn’t seen those videos. So, social media is primarily where I think of for pre-encounter perspective. I also think you have to think about it too in terms of a family, maybe from a more illness perspective. You have to be aware that something like 65% of people, when they’re dealing with a medical problem, have already done some searching online to try to figure out what might be going on.

And so it might not be me using it for pre-encounter perspective, but I know my families are and so populating the internet with high-quality source material that they can come across and find. It’s not unusual for a family to come in after having dealt with something for them to say, “Gosh, you know, our kid had a febrile seizure, but we found your article about febrile seizures and we had already read it,” before they came in. That’s like ultimate for me because that’s why I got into this space, was try to provide good information out there for parents to come across.

Scott: You’re setting good expectations and providing good, well-vetted information for people before they come in. They then can get a running head start when they’re meeting with you. And then it seems like from a post-encounter, you’re now able to have a conversation with them and maybe settle what could be really bothersome things with just a quick comment back to them. Is that the overarching strategy so to speak?

Dr. Smith: Sure. Most of my post-encounter stuff though is gonna be done via our patient portal. We have a fairly clean patient portal that allows the family to send me a direct message, just got push notification both ways. So, that actually is nice because then it filters right into the patient’s chart.

Scott: That’s interesting because as I was thinking this through, you’ve got it connected to your EHR, electronic health record system, and then is that “billable,” that kind of consultation, or is that just part of the bundle so to speak? And I’m sorry to be so economic about it, but I’m curious.

Dr. Smith: There are workflows where you can build in a payment model and you could submit them to insurance. For the most part, they’re gonna deny those claims. And so, from my perspective, the sort of brand bump that I get in a sense from providing that level of service is worth way more to me than any $5 charge I could get for responding to a message. Because I guarantee you, that family tells one other family about it, and it becomes well worth my time to respond to those messages.

Scott: That’s really interesting. And I’m fascinated by this, and I know Michael had some questions about your clinic set up.

Michael: Yeah, I can attest from the other side though of being that parent on the receiving end of that. My wife is the one that you know, ends up dealing with a lot of the following up with the doctor and asking the questions and all that. She’s far smarter than I am in that area. You know, to know that my daughter is okay, but then also to see how much relief that brings to my wife certainly has helped us sing the praises of our pediatric team for sure.

I’d love to hear more about how you designed your clinic, and what was different about it, and how you feel that it helps improve patient care?

Dr. Smith: Yeah. I was fortunate in that I came to my health system, Cook Children’s, already having practiced pediatrics for like four years. And so I had some ideas about kinda how I wanted things to work and how I, you know, building a practice, I wanted things to be different but had a good, like, functioning knowledge of running a practice and taking care of patients. So I had a little more like mental bandwidth to think through how things were gonna be different.

So, that really set me up well to do what we did. And basically, the system came to me and said, “Hey, you know, you have clearly some ideas about you engaging with patients that are a little bit different, a little bit more forward-thinking than many pediatricians, many doctors too. And so we’d like for you to start your own clinic.” And at that point, the location that we picked, we didn’t have a clinic in the area, so we’re basically starting from scratch in how to shell.

So that afforded me some time to really lean into what parents in this area wanted. And so I was able to kinda solicit some general feedback via my social media channels. And ironically, even though I’d never practiced in this area specifically, I had a ton of followers up here. It just have just happened to be so. And so I realized pretty quickly who was from around here who was responding to my questions about like, how would you like for things to be different?

And then I took some of those people who were responding quite a bit, had some good ideas and really talked to them a lot more, including some email follow up, and then even some personal meetings where we met with them and interviewed them and got some ideas from them and really just kinda leveraged their expertise as parents and grandparents. And we have a lot of different types of caregivers who might be the person bringing the kiddo into the doctor and built really everything…or not everything. We built a clinic that was centered around their ideas, which really was a refreshing way to do it and led to some subtle changes that have really made a huge difference for our families.

Michael: I’d love to hear a little bit more about that. Just for a personal experience. My daughter was involved in one of the local hospitals picking out the design for the room so that, like, when you go in to get scanned, it’s not such an intimidating process, you know? It’s a fun design, but I’d love to hear a little bit more about some of the details that you think really made a difference.

Dr. Smith: Yeah, so a couple of things. You know, one of the things that…it was really cool because, as I’ve worked through this and wrote down ideas and started building them, what it really came down to is something I call the three Es. And patients really wanted engagement. So, they wanted a physician, a pediatrician who, when the patient was in…when you’re in the room with the family, that the pediatrician was engaged with them and not just spending 100% time documenting in the EHR or you’re distracted the whole time.

They want somebody who’s really engaged. They also wanted engagement in the community. And so it’s really important to them that we have a float in the 4th of July parade that just happens to run right in front of our office. And so we knew early on that those are the types of things we needed to really be involved in, in this community. They wanted efficiency, and so that’s the second E. And so we really built it everything that we could, you know, all of our digital health, all our check-in tools.

Everything is to put minimal burden on the patient so that by the time they’re back in the room, they’re ready to go, and we’re doing all that as fast as we can and not having to fill out the same forms over and over again. They want it to be able to access information through the portal. So we’ve turned every portal feature we can on so that they can get as much information as they can through the portal. And the last thing they wanted was empathy. And so they wanted, you know, the whole staff to care. And so we’ve really worked hard in terms of our recruitment of the right staff who could provide that high level of empathy.

You know, it’s not uncommon for the patient to hear from every staff member, you know, “I’m sorry that they’re sick today,” or, “I hope they feel better soon.” And we really train our staff that every phone call, even if it’s tenth ear infection we’ve heard today, maybe something that that family is really worried about for some reason or another. And so we really work hard to make sure that they’re getting that high level of empathy from the first time they call until the last second that they’re walking out the door.

Scott: That’s really great. You know, the use of social media for a lot of…or just good patient education, you’re basically providing well of that good patient education, and you’re using social media as your platform, whether it’s I presume Instagram or Facebook or just content on your website, which is not social media, but it’s just good content. Let’s talk about that.

Something very simple for lots of parents with newborns, they rule out for the ear infection where the baby is crying, and is stuffed, and they are new parents, and most of your time is spent looking inside and saying, “Yep, that’s a head cold, and I’m sorry that you won’t be sleeping a lot for the next two days, and here’s some thoughts about that.” Do you put that kind of info up on your site so parents can feel a little bit better beforehand after that same info can be, I guess, correct?

Dr. Smith: Yeah, I mean, so just thinking about that one specific use case. So I have a couple of different articles and a couple of different social media posts I’ve done over time about like, “Here are the five real symptoms of an ear infection,” you know, because there’s so many old wives’ tales out there about it so that my families, and a lot of them do, they’ll search my Facebook page and find old posts, or they’ll search on our newsroom and find old story written that will actually give them some guidance about whether, “Oh, do I need to book this appointment, or is this something I can just watch at home?” And so I think we try to help guide them through social media and through content to making the best decision about whether they even need to be seen or not.

I mean, secondarily, like on the back end of that visit, let’s say they didn’t have an ear infection. Well, whenever a child comes in with a cold, one of the things that I do on the back end on their after-visit summary is I have, you know, quick texts, and I have…basically, with just a few keystrokes, I can drop in a whole bunch of information, and I’ll even, through their after-visit summary, link out to articles I’ve written about the condition. So fever is probably the best example because I’ve written so much about fever.

Anytime a child comes in and I diagnose him with fever or a viral syndrome and I’m not necessarily treating an ear infection or strep throat, I’ll send them like seven or eight different articles they can read about fever after the visit. So that they go home, and they’re like, “Okay, well, should I treat this or not? When shall I let it run?” Like, they’re gonna have all that information in their inbox that they can review after the visit.

Scott: Yeah, and that’s a great balance of, especially for Generation Z, of empathy as well as efficiency. To your point, they’re used to getting all this content online, and you directing them to that well-vetted information has got to be something you get a lot of positive feedback regarding, I would assume.

Dr. Smith: Yeah, definitely. You know, they’ll come back in a checkup two months later and say, “You know, after we saw you, his fever went really high. But we read your articles, we did what your articles said. We didn’t even call you because he was doing better the next day.” And I’m like, “Yeah, perfect. That’s exactly why I do what I do.” So that’s very validating and very, you know, reassuring that it’s actually worth it and the parents are seeing the value of it.

Scott: And do you feel like that kinda strategic use of social media that we’ve been talking about enhances your relationship and solidifies that bond?

Dr. Smith: Yeah, no doubt. So, definitely, I think the parents who came to me because they knew about me from social media or who follow my page, we have a different level of relationship than the parent who didn’t or that who’s not really involved in social media, and that’s fine. I mean, I have great relationships with everybody. It’s not important to me how you wanna sort of engage with us. But I would say that, like, it’s clearly different when I post stuff about my family as well, you know, and I’m careful about their privacy and everything.

But at the same time, like, I think it’s important for my families to know that I have some of the same struggles that they do. And so there’s another level of connection just based on that piece too that sort of endears you to them in a way that’s different than, you know, the doctor that is standoffish or is not warm and is not involved in some of these things that are really a key part of their lives.

Scott: It’s very interesting from my perspective having… My kids are now in graduate school or beyond. But I remember I was married to a doctor with two young children. I’m a biomedical engineer who worked my way through school as an EMT. And I can’t tell you how uncomfortable I still felt with both of those kids when they were young with something as simple as an ear infection, and I was empowered with a lot of good information.

So this is just great stuff for people who…they can have MBAs for all you care, but it’s their child, and it’s their young child, and they just don’t feel like they have everything they need and being able to just go online and see it one more time. “What did he say?” You know, “Okay, now I feel better.” That’s gotta be great for them.

Dr. Smith: Yeah, I think it is. I think a lot of physicians worry about, “Oh, it’s gonna take me so much time.” But, like, if you really think about it, if I’m going through my little spiel for fever, but I know it’s a family that’s on the portal, and I say, “Hey, let me just say these two or three things, but let me tell you what’s more important, is I’m gonna send you out a whole bunch of links of information that you can read.”

Or they’re much less likely to spend 20 minutes asking me more follow-up questions because they know that that information is coming to them. So just that reassurance that it’s there, whether they look at it or not, just they know that it’s there and they can access if they need it, it ends up being a huge time saver for me because I’m not having to answer five million questions thrown at me. I’m giving the two or three highlights and then giving them more resources that they can access if they need it.

Jared: Yeah. Dr. Smith, I remember, you know, besides your approach to this whole patient-centered, you know, patient-designed clinic, just your whole approach to care, the one thing that has stuck out to me over the years that we’ve known each other that you’ve shared with me is this thought towards the clinical community about the use of social media.

And I remember you kind of pointing a phrase to me about how towards other clinicians that if you’re not producing good health content out there, you know, how can you complain about the bad information that’s out there and those who are…you know, how can you blame somebody for trying to Google answers for their condition or what’s going on?

You know, how can you blame them if you’re not even attempting to put out good vetted information out there? You know, has that conversation with the rest of the clinical community changed much or what are you seeing there? Are there more clinicians who are open to it and are trying to explore how to do that? What’s been the change lately?

Dr. Smith: Yeah, it’s definitely changing a lot. You know, I wrote my first blog post like nine years ago almost and that was when I was on my own in private practice in west Texas. And, you know, then, everybody was like, “Oh, you’re crazy. Why would you wanna do that? People are just gonna get…you know, it was a big thing then. You know, now as my role has just changed, now I’m the Medical Director of Digital Health for our health system, and we had to do that because so many physicians wanna be involved in writing. Then we had to have somebody with some supervisory role to go back to them and say, like, “Actually, we can’t put this out there, and here’s why.” It has changed with time. I mean, it’s happening for two reasons.

Number one, I think that our more seasoned physicians are seeing the value and seeing that perhaps they might have overestimated the risk, and so then all of a sudden that reassessment of risk versus benefit is changing for them. Number two, you know, we’re recruiting and hiring more and more recent graduates who are millennials and maybe some Gen Z physicians. And so, for them, it’s like, “Why wouldn’t you do this? Everybody should do this.” And so, it’s just a little bit different perception from their viewpoint.

And so I think when I first started at Cook, on our newsroom, we had had like somewhere in the realm of like 30 physician contributors. We’re now approaching 300 that have contributed to our newsroom or to a social media post of some type. That’s now a half of our clinical staff. It’s been pretty interesting to see that dynamic happen. Where I was kind of originally thought as the crazy guy, now I’m kind of seen as the resource for how to do it well and get it done right. It’s just a mind shift change that’s happened.

Scott: You know, I’m thinking you guys might actually start focusing on, from a library perspective, you know, your volume so high, how you structure pathways to get to information quickly and effectively and maybe even get some of your more recent contributors to add where there are holes rather than where you’ve already got a few articles kind of a thing.

Dr. Smith: Yeah, definitely. Management of the amount of content is an issue because we do publish like a newsroom, so we’re publishing nearly every day. Last time I counted, I was near the 500-article range just myself. And so it definitely creates some issues. And, you know, it’s interesting because, you know, I’ve written about fever. You know, like I said, I think I have like 10 articles on fever now. But, you know, we also wanna encourage a new doctor who wants to write about fever to go ahead and write about it because they may have a different perspective, they might resonate in a different way.

And so we’re definitely always balancing, like, how do we stay relevant, both with evergreen content but also with breaking news? You know, if we have a measles case in our area, how do we handle that in a way that’s responsible and perhaps a little bit differently than the media sources around here would maybe try to escalate fear and maybe we need to be responsible with our fear and encourage people to pursue vaccination but not raise the red flag and cause a whole bunch of alarm either? That’s been kind of interesting, is that navigating that balance too.

Scott: I’m curious, like, around the vaccination issue where, and I’ve made this joke many times before, two plus two is four, the world is round, and you should vaccinate your children. These are just facts. When you put this information out there, and you’re doing such a good job of getting lots of good information, do you see that you’re getting less questions that frankly are way out there, that, “No, this is not a good idea not to vaccinate your child.” Or do you still see that? You know, where some sort of strange piece of information or, just to use the vaccination issue, where somebody still comes in with that kinda stuff?

Dr. Smith: Yeah. We take a conversational tone in our social media content so we still get a lot of questions, a lot of feedback. And for certain topics, vaccine as an example, we will get quite a bit of pushback from certain groups. You know, anything…our goal is always just, “Let’s just point back to the science. Let’s point back to the facts. We’re not gonna get in the mud with you, but we’re gonna point to validated, verified information, whether that’s coming from the GDC, BEAP, you know, really using our organizations that provide guidelines and quality evidence. And we’re gonna point back to them and be reasonable, but also we’re not gonna let a lot of misinformation just live on our social media posts without responding to some degree.”

So I would say it’s probably pretty similar in terms of what we get, but we’ve definitely gotten a little bit better about how we respond to it in a way to just make sure that the good information is out there and then not stress too much about somebody is negative.

Jared: Dr. Smith, thanks so much, as we kinda wrap all this together, for giving us an update on how things are going for you and just your approach. I’m not even trying to be dramatic here. I was getting a little bit of, you know, chills coming up and down my spine when you said like how much progress you’ve had with having other physicians contribute to blog posts and to online information. I genuinely feel like that is an important trend on the marketing and business side. We’ve gotta pay attention to that and support that in every way we can to really, at the end of the day, have content, make people better and healthier. So, thank you for everything you’re doing, and genuinely, we appreciate your time on the program today.

Dr. Smith: Yeah, thank you so much for having me. It was fun.

Michael: “Paradigm Shift of Healthcare” is brought to you by P3 Inbound. You can find our full archive of episodes with complete transcripts at paradigmshift.health, and recommend to guests a topic on Twitter @p3inbound. Thanks so much.

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