Exploring the Human Side of Healthcare with Dr. David Salko

How are you today? I'm great, thanks. I'm so happy to be here. This is really an exciting moment for me to come and do this show. Oh, well, I should have asked you 10 years ago, because we've known each other for probably 25 years-ish Probably. Yeah, since through residency. So there were two things that I'm accomplishing with this. You may have some agenda too, but I'm really happy to be here because one of my New Year's resolutions was to crave conversations because I think they create connections, if that sounds like too much, maybe it is. But craving conversations with people, one-on-one, it kind of gets you away from the cell phone. It gets you away from asynchronous conversations, and it's an art. And I think the other is that I wanted to create some space in my life in the time that I spend at work or everywhere else for creativity and conversations, I think allow me some opportunity to be creative. Well, that's perfect. Both of those things are very much in alignment with I think what we're going to explore today. Good. That's great. So moving backwards, you and I are both family doctors. We both have fathers who were family doctors, we both have other family members who have been in medicine. And you and I both have spent significant amounts of time caring for our communities. And actually, I would also say probably even more important, you and I both, I think feel very strongly about just families and our families and other people's families. So I think there's a lot of shared social landscape that you and I have. I agree. Yeah. But the reason that I thought, oh, I haven't talked to Dave recently and why don't I do it on camera, is because you do this wonderful thing with the Dempsey Center and you're representing it through your bow tie here. I got A snazzy one on today. It's a very snazzy bow tie. So let's maybe start with that. Talk to me about the Dempsey I've been with Central Maine for 17, 16, 17 years, and they've been doing the Dempsey Challenge with the Dempsey Center in the Lewiston area for the last 15, I think this last one was the 15th anniversary, and three years ago I decided to do it, and there were certainly some of my own personal reasons for doing it. And also it was just there was a time I needed to do something different. I needed to do something new. So the first Dempsey challenge I entered in was about three years ago. You raised some money for the Dempsey Center, which is a completely free service to people of Maine and beyond Maine now that have are fighting with cancer. So the challenge in the Dempsey Challenge I think is meant to spread across that there's those with cancer that are experiencing challenges, and there's the challenge of riding your bike for a long time. So each time that I've done something like this, I've run marathons. I know you've run marathons. I click the little button that signs you up and then you swallow your heart and go, okay, I guess I have to do it now. I've committed. So the commitment itself was motivating. The first time I did it was on a mountain bike, which I don't recommend. I rode 25 miles on that, and it was more about completing it. So I had some support. I had Mike Stead, Nikki, who's another doc at Central Maine, right alongside me and probably if he didn't do it, I'm not sure that I would have. So it's nice to have a partner in crime. Sometimes it pulls you into it. And then after that season I said, well, maybe I'll get serious about this as a sport as a way to stay healthy. And I got a road bike and then did the 65 mile, and then last year I did the 65 mile again. So I'll probably plan on doing that again. The athletic challenge I think is exciting, but now I've learned a little bit more about the Dempsey Center itself. I didn't know that it was all free before. Now I do. I've met some of the people. I've had a chance to have a picture with Patrick, which I think my wife is mostly jealous of. I think he's a great guy as She should be. Actually. Dr. McDreamy, doesn't anybody want a picture with him? They do. So I think he's a great guy and the brief conversations we have, he's so supportive of the community, which is really cool and supportive of the work that the Dempsey Center does. So giving back to that felt good. I think if I were to go online and say, Hey, I need to raise money for something. I think based on the work that I do as a primary care doc, it's very giving work and you explore your generosity a lot in what you give for time. I don't like asking for stuff for myself, but this felt really good to be able to say, Hey, I'm raising money for this thing. This is a really good endeavor. Can you support it? And a lot of people did, including yourself, which I appreciate. So this is something that I think will grow for me in being able to support the Dempsey Center with their, I guess spreading their ability to take care of patients and support patients through cancer. It really helps a lot of primary care offices too, because we might not have the same amount of time to talk to somebody about a cancer diagnosis or the mental aspects that go into being a survivor of cancer. So those things were inspiring enough and getting into it I think was like most of the things in my life, they just showed up and I said, all right, let's have a go at it and I'm really happy with it. So the thing when I visited the Dempsey Center that I was struck by is that it's a very holistic approach. They meet patients where they're coming from. So if you're a patient who needs a group counseling session, then they've got that. They've got resources, they do acupuncture. I know you and I recently were in touch about that. They have massage, then they deal with patients of all ages. And I think this is something that, particularly in the Lewiston area, but certainly in many parts of Maine, there's just not that access to for patients. And I think now they're going to have mobile access, so they'll be able to go to more patients rather than having to come to the center, which is exciting for them. Certainly I think you can agree from the primary care aspect and what we've done as family physicians, that there's more to medicine than just the medicine. Have you selected the right anti-hypertensive medication? Are they on a cholesterol mill? Are you following all the guidelines? There's way more to that than just the medicines and taking care of people. And the example of the Dempsey Center is really about taking care of people's spirit, their heart, their mental health. A lot of those things are wound up in that. When those things are well and supported, I think the medicine goes much better. I've taken care of many, many people that have had cancers. The patients that I've seen do, well, I guess from a medical standpoint, are those that have the support and they seem to have a mental state that's a positive outlook. They always have a good attitude even when things might not be so good, they take on the challenge, like the Dempsey challenge, they take on the challenge of that knowing that the journey is really where they're going to get effort from, not where the end is going to come. So I think that's important to continue to have venues like the Dempsey Center and probably in primary care offices and other offices to support folks' mental health and how they get through things. Well, that's a really good point. And I know that there are many offices now that have co-located behavioral health services, and I think that is really powerful because back in the day, and probably when you and I started, we actually had a little more time to talk with patients. We had our schedules were not quite as jam packed. And I actually believe that patients have become a little more complicated over the years. I agree. The system of medicine is a tough one. It's driven by things like volume and access. And medicine only gets more complicated. It's not like we got rid of three classes of pharmaceuticals, we just keep adding them. So there are a lot of challenges. Patients have become more complex when they do get an office visit, there's low access. They need more in that short period of time. And that's a challenge. I don't know that, I don't exactly know how the system will solve that. I'm excited to be a part of it, of course, but I think it's going to take a lot of creativity and a lot of efforts to find different venues to meet that challenge that the patients need. Well, and I think that is the opportunity for us in medicine is that we kind of open up the definition of a team and we open up the possibility that patients might have other places that they can go to access different parts of their care. And it doesn't always exist. But I think when it does, it's so powerful because we as doctors or if I'm a nurse practitioner or I'm a physician assistant, I just cannot do everything for a patient. And I'm not sure that we ever really should have tried to be everything for a patient. That's my opinion. What do you think? I agree. Historically, the training was the one person show, you're the doc, you make the rules, you set the prescriptions, you do all the things. Now realizing where medicine has gone in the last two decades, it's a team sport. And if you're not playing a team sport, you're probably at much significantly higher risk for burnout, which I prefer to call lack of engagement, but everybody's a little crispy. But knowing that you have other people helping you care for your patients and their needs is vital. Now, the idea that one person can do all that is it's not even imaginable. So I know that you and I both have, we happen to have fathers who had practices in small towns for many years, and having met your mom who just a wonderful individual also was sort of part of that running of the office when there was a family practice that your family had, do you feel like there's something that we can learn from those spaces which increasingly rarely exist from having the small practices in the smaller towns where everybody is known? Yeah, one of the probably richest elements is the relationship and trust. So if you have a team and everybody really knows each other, they know their strong points, they know their weak points, they know what they need help with, they know when they're run down and you have the trust that, Hey, I need this done. This is a today thing. And when it's family backing you up, that's very strong, but it grows from there. And I think the relationships and trust that existed in those small small town one dock offices were amazing. And that element needs to still live in today's system. If you don't have some of that glue that binds people together in an office, it's far less successful. It's always the idea that the sum is greater than the parts. And that's really demonstrated in small family medicine offices of the past and maybe of the future if we can figure that out. Given that my dad, Charlie, because he was a, he's The reason I came to Maine. He's The reason. Okay, well, there you go. The reason you came to Maine, he helped educate literally generations of family doctors and arguably other clinicians around the state and probably around the country. It was always funny for me to meet his patients because they'd say, oh, you're Charlie's daughter. I've heard about you. And it became very clear that my father would mind the stories of our 10 sibling family to share with his patients to help with their parenting conundrums, let's just say. And so I would hear stories that were fed back to me about myself that I had not realized had been shared in a really respectful way. I think. I'm wondering, did you ever have that experience yourself where you would hear about things that your parents might've shared about your experience in a family? I think that had to happen on a regular basis. I sometimes tell my boys, I'm like, there's two ways you can learn things in life from your own mistakes or someone else's. And I think along the way sharing, I can remember that my dad would share stories and definitely you knew we were part of a crowd when I was in school or anywhere else, they would pick out the SCO kid. I was one of five kids, so only half of what your dad was created, but still a lot, but still a good pile. But you knew that. And I know he shared stories about us in the office, and I did get a chance to practice with him later. I don't think anything came back too aggressive from it. But people would often come in, we call them super adults now. They would come in and say, oh, I remember when you were little. I remember when you needed a diaper change here or there. And those kinds of things can be embarrassing, but it was amazing the amount of trust they applied from the stories that he would tell. So his stories might've been about us growing up or how we did in sports or how we did in school, but he was sharing this level of love and trust that he had for us and for me. And I got to feel that on the other end. And full disclosure, I do the same thing. So I go to the office and I might share stories about my kids, whether they're dating or how they're doing in sports. And I think that allows me to be a little bit vulnerable for patients, and it allows me to share some aspects of my life that I've learned from. They might not be super personal, but when it's an aspect of my family that I feel willing to share, I think it brings that human element in and it says, I'm not some sterile white coat wearing chat, GPT, AI bot providing you medicine today. I'm a real person and I'm going to go home and I'm going to see my family after this. And I think the patients I've cared for a long time, they know my family, they know my style and I think they appreciate it. And they'll often do things like, I know I came in the last appointment today, but I know you have to get home to your family. And that feels good. Then there's a shared respect in what we're doing, and that doesn't happen as much anymore. So it does take time as you've practiced for a long time, you get, I think it's probably somewhere around a decade of caring for people that you go, wow, I follow these people for enough time that I'm getting a lot of ripe fruit. I'm gaining the rewards of the time that I've spent caring for these folks. That feels really good. That's a real good, I think hook to stay in primary care for anybody considering it, stay in it, it's worth it. It's tough, but the longer you go, the more reward there Is. I think that's definitely true because change takes time. So if you have a patient who comes to see you, you can't expect that they're going to shift everything about their life and have a healthier lifestyle as a result of one conversation. Sometimes it can feel a little bit less rewarding than my sister and my brother, both whom are orthopedic surgeons. They go in and they fix a body part, you and I, the fixing of the body parts, that doesn't happen with one surgery. So it is something that requires an investment. So I guess I wonder, one of the things I asked you about before we came on is that I've obviously had health issues and I've mentioned on air before that I went through cancer myself. And I know that you also have had health issues for sure. And as a physician with your own sense of vulnerability and being a, do you think that that has lent a different perspective to the type of medicine that you practice? Definitely. I mean, anybody that goes through their own health challenges, I think they realize what the system provides, what a value health in itself is when you don't have it or lack it, there's a lot of fear. There's a lot of anxiety built into that. Sometimes there's anger, so there's a lot of emotions around saying, wait a minute, I'm sick. Generally people who are younger, sometimes they referred to as the Superman or the Invincibility syndrome, the idea that I will never get sick. And one thing I've learned through my health challenges is that I'm really no different than anyone else. I'm built as a human. I will break down as a human. And the longer you do medicine, you see common courses and paths where people break down, I may have an advantage. I can see those pathways so that I can better prevent them. And then you share with other people how to prevent them. My story and probably the most important thing that I learned was you have to have certain things that you value in your own health. And one thing that I was short-changing myself on a lot was sleep. I think we're trained in a certain way to say, I may not need that sleep. I'm a resident. I can live for 48 hours on a few cups of coffee, maybe a few more. When you're younger, I do believe it's easier to recover. So it reinforces the idea that you don't need sleep. I have diabetes, and that's a challenge to be able to manage blood sugars, eat right, not be tempted to have ice cream or cereal at night. Everybody goes through this and I'm happy to share that with patients because I realize everybody goes through those same challenges. So having that and the poor sleep, I did end up with an infection in my back and it was pretty significant to have sepsis and osteomyelitis, which is an infection in the bone. And that was a wake up call to me. I think my wife would probably share. It wasn't enough of a wake up call. I got it again two years later. But since that time there's been a shift in how important I know certain essential elements are. So the lifestyle medicine that we might be more likely to talk to people about sleep is important and it's an essential element. I joke a lot with patients when they come in, especially when I see them for physicals, I say, there's only two medical problems. It's only two. You only have to worry about two things. And I simplify it for students that way too. I said, there's neglect and abuse. You're either neglecting your body or abusing it. And if you could eliminate those two things, that's most of lifestyle medicine. So I've enjoyed using that simplification to tell people to quit smoking, to get more sleep, to eat a little bit better. So they're making healthy decisions today for their tomorrow. I've never heard it simplified to that extent before. And I think it is really powerful because it just makes something pretty serious out of something that we may not think is that important. Like, oh, well, I'm just going to stay up a little later and I'm going to finish writing notes on my patients. I'm just going to get up super early tomorrow so that I can do chart prep for my patients. Both of these things I think are real life examples you might be able to relate to. They are, yes. And you think of it as like, well, it, it's what I need to do to do my job. But ultimately if that, let's call it abuse or neglect, either one, I mean it does leave you less able to actually do your own job and to successfully navigate getting a life-threatening infection if you have insulin dependent diabetes, I pushed myself to the limit and the limit of that was the lack of sleep. And I guess the idea of maintaining that for me was important. It was also important I think for me to share that with people around me, which is what I encourage patients to do a lot. When you make a goal or you're going to make yourself a health challenge, tell as many people as possible. Don't fear the failure of it because you'll still learn something. People that attempt to quit smoking, I don't know, it might be 10 times they need to attempt. So those are lessons that I can take from my own experience and share with patients. And I think it does take time to do that. I don't know that people would want to do that right off or how they feel comfortable doing that, but I think it's something that probably should ease its way into medical education that we are normal vulnerable humans and we go through some of the same things that our patients do in doing that we can actually better serve them no matter what our outcomes are. But sharing those challenges with patients I think can bring them down a path of better health. We might not always see the outcome, and I think that's part of the bummer, but you never know exactly when you're going to influence someone. So I think you always have to be ready to do it, whether it has an impact or not the first time or the 10th time. I Agree with all the things that you just said. And I also think that there's this interesting thing that we forget about, and that is that we're modeling behavior. So when we bring something to the table and we say, I think it makes sense for you to explore these as options for your life, but then we're not doing those things ourselves. That doesn't really make us very trustworthy as far as caring for patients. I'm finding it's the same as being a parent. So you aspire your children to do the best of all things, and we always want the best for our family, especially our children. And I wouldn't want one of my kids to trip over the same thing that I did with sleep. But yet today's environment pushes kids pretty hard, whether it's school or college or sports or something else, it does push 'em. And the end game I don't think is necessarily just being the most productive or the most patients or have the highest volume or revenue. The end game that I think I enjoy the most is people will remember how you treated them. People will remember how it felt when you were with them more so than most of the stuff that we say. So we can share, I'm sure you'll share with patients sometimes here's a journal article, and that might not be where they're at, but we can share it through another way. We can share it through a personal experience and patients will remember that it'll become memorable for them and stick a little bit more than just some static statistic that you can share. And I love this idea of the story because when you're trying to convince somebody of something, sure, a statistic is very striking. If you are age 50 and you are a male, you're opportunity for having a fatal heart attack is significantly increased over when you were 30 and whatever statistic that is, please don't be able to pull that up automatically because feel embarrassed. But that is striking. And also when you say, and I was in a scenario recently where there was a person, and this actually happened, it impacted this person's family. I think there is the understanding that it's not just people's rational minds. We're dealing with it's people's emotions and that as any sort of clinician, you actually have to understand how to communicate with people in order to help them move through a change if that's what needs to happen. I do think, as I mentioned earlier, there is an art to communication just in listening to a patient. Sometimes when I see another conversation happening or I'm mentoring somebody, I can tell that they're thinking about their response. So they may not be listening to necessarily understand, but they may be listening to reply, which isn't always wrong, but if you are really in the conversation, you're listening, you're absorbing, and then you can understand their perspective and better reply. So I think there's things that come. I feel very lucky. I mean, I get to have 20 to 25 conversations a day with different people. It's someone different every turn of the door, but you learn some from each of those and you sort of perfect your art of how you approach each person, knowing them, knowing you what they expect, what you expect. And over time it really becomes fun. It really becomes rewarding. I love that because some people are more numbers, some people are more, some people you're talking to their emotions, and I think you're right. Until you actually spend time with somebody, you may not know that. And what I've found is that you is that I have over the years of many years now of sitting with many people in many conversations that I can start to recognize patterns. I'm not going to pigeonhole them and say, oh, I know this person immediately just by this pattern that I'm seeing. But it's more like, oh, there's a kind of a conversational thing that I've noticed before. So how can I meet that person in a way that feels comfortable to them and actually utilize these years and years of experience having conversations? I think it's really awesome. And I'm sure you've been to this stage too, where now you can make some of those implicit things explicit. You can explain to someone, well, I sat that time and didn't look at the computer because, and you had a sense of that and a real ability to articulate that early on in mess. And I know I didn't have that. I just walked in the room and hi. And then people would judge based on how I came in, I would judge based on what I saw. And now it's different. You can break down some of those stereotypes and really approach the conversation fresh, but also with this more expert experience of playing the sport of conversation. There's two things that I give you so much credit for Dave, and one of them is that like my father in his generations of bringing people along in family medicine, essentially you've been a teacher for again decades now. Yikes. Yeah. Which I saw in you because I believe so I think you were a year behind me in residency, maybe two. Okay. So we were in residency at the same time. But even as a fairly young doctor, straight out of medical school, you always had that gift. You were always a teacher. But I know that you've just continued that all the way through, and it's so powerful that you have done that for people who are coming along. And also part two is that you are so great at reaching out to colleagues. You're so great at you. And I regularly we'll just be like, oh, you free. Okay, let's take 10 minutes. Let's talk about this. How are you doing? How are things? And I think right now in medicine in particular, it's so challenging because we've lost a little bit of that professional journey idea as learners early on and then as professionals in leader, mid-career, whatever we call it. And you've managed to create this continuity, which I think is really admirable. Thanks. I always get embarrassed by compliments and maybe that's something that keeps me going. I don't necessarily think so much about what I do or how many students I've had. I think fondly about most of the ones I've had because I've had some great students and there's the benefit of teaching, I get a lot out of it. So there's something there for me. Sometimes I'll say, maybe it's the 10000th time I've seen someone with strep throat, okay, here's your antibiotic out the door, but it's not an urgent care. You can use that to dance around the conversation with the patient, and there's an enjoyment in that. Maybe that's a little too selfish, but it's fun. I enjoy doing it. Not every situation is as easy as strep throat, but it's still an evolution of time with these patients. It's really enjoyable. So I wouldn't keep doing it. These things that you say I do so well if I wasn't having fun doing it, finding ways to have students find fun in it I think is sort of my, I'm feeling drawn more to that. How are we creative in our jobs when our jobs are becoming maybe less flexible? You've got the EMR, you've got restrictions on time. There are many rough spots in primary care, but where can you find space for creativity? I've tried to find space for that in myself, and I'm hoping that over time, that's something that I do more. So reaching out to colleagues to me is always exciting. I like to hear what other people are doing, right, what's going on? How do you run a podcast? This is something I dream about. I'm having my dream right now. Anyway, it's something fun and exciting. I think that people pursue their passions and when you see it happening, it is joyful for me and joyful for them. I'm glad you were able to accept the compliment. I'm not great at accepting compliments myself, but also I know you to be a very humble individual, so I'm sure it is hard to hear a compliment, but sometimes, yeah, I mean it requires additional energy on top of being a doctor, a father, a husband, a brother, a son, to actually continue to do these things, to connect, to remain dedicated to being a teacher, to kind of continue to work on. So I think the community building that you've done, it's very meaningful. So if you can accept that compliment as well, I want to make sure that you hear that from Me. Thank you. So switching gears a little bit, I had the opportunity to interview your daughter. I think she was early on in her art career at Ringling College of Art and Design. That's Which I'm sure you're very familiar with the naming of because you've paid probably some money towards them over The years. Yes, we've support education. You support education, support education for everybody. Yes, exactly. So I'm interested to hear how she's doing. And I know you have a daughter also who went into nursing. Nursing. Yep, yep. And you have a couple of other Two boys that are hockey stars. Yeah. Great. So these are all good things, but I am interested when you talk about creativity, you're clearly fostering creativity in your own children and in really different ways. So I'd like to hear how they're doing, if you don't mind. Sure. I think that having the group of kids that we have is incredibly amazing. We're very blessed. Jen and I all the time have many conversations about our kids, creative and otherwise, children are challenging and you have your own and they have to find their own path and their own passion. I think one of the biggest challenges for my eldest was what Covid did to create relationships through college. And that environment is incredibly challenging for kids now to create relationships, and maybe this is why I am taking this year to create conversations. I call and talked to her. In fact, I talked to her just before I got in here and I said, Hey, guess where I'm going? And she said, oh, I was there. So it was exciting for us to share that. So right now, she has moved to Nebraska and she's pursuing other jobs and other interests. She's been very interested in tattooing and using that art and design. And I think initially, and this is me being vulnerable, initially I was like, what? Tattooing? Oh, no. But her reasoning for wanting to be creative in that environment was also something that I share is being close to a person. It's a very personal thing to pick out and have a tattoo and for the person to give it to you is kind of like in the office. I'm giving someone their first vaccine. You're explaining it, you're talking to 'em, you're designing it with 'em. So I think she will continue to develop herself with her creativity and also working with people, and you probably know this at your kids, you feel like you know them better because seen their trajectory. You're like, oh, I knew you when you were little and you've always done this. Dr. Dave Salko