The Most Powerful Tool in Medicine Is a Stool

[0:00] Good morning, Dr. Tolcher.
[0:01] Welcome to Look for the Helpers,
[0:03] the Engage Podcast.
[0:04] Really awesome to get you to spend your time with us today.
[0:09] Can you introduce yourself?
[0:10] I know you have a lot of hats.
[0:11] Co-owner right of Parkway Pediatrics in Calabasas.
[0:15] Pediatrician, of course.
[0:16] Yeah, good morning, Blake.
[0:17] It's great to be with you and thanks for having me.
[0:19] It's true that I, 15 months ago,
[0:21] opened a private practice in Calabasas
[0:23] with Dr. Bethany Stafford called Parkway Pediatrics.
[0:26] It's been a dream of mine for 20 years.
[0:28] In a couple months, I'll be 30 years
[0:30] in private practice in the area.
[0:31] So it's been just quite a journey and I'm not done yet.
[0:35] I hope to get a lot more done in this space
[0:37] over the next, I don't know, decade plus.
[0:39] And so yeah, my other hats is that I'm involved
[0:42] in a few other areas in the pediatric space.
[0:44] Mainly, I've been connected
[0:45] to the Children's Hospital Los Angeles Care Network,
[0:48] where I've been the co-chair of the Quality
[0:50] and Care Transformation Committee for a little bit.
[0:53] Yeah, and you've had experiences, right,
[0:55] with other group practices
[0:56] and working in more of an administrative role
[1:00] in a pretty large conglomerate, right, overseeing that.
[1:03] So you've had a lot of different,
[1:04] I guess, experiences within the helping profession
[1:08] and you're part of that, pediatrics.
[1:11] So that's where, you know, I know,
[1:14] because I've seen you talk,
[1:16] you have so much knowledge about the brass tacks
[1:19] of helping kids and being a pediatrician.
[1:22] There is so much need for that.
[1:24] That being said, I was, you know,
[1:26] thinking about sitting down and talking to you
[1:29] and you're someone that, just listening to you,
[1:33] I feel like aligned with somehow.
[1:36] I don't know what I pick up on,
[1:39] but I'm interested in a conversation with you today
[1:42] that is a little more, I don't say more depthful,
[1:47] but I see it as an opportunity to talk to someone
[1:49] that's lived a lot of experience in this profession,
[1:52] has probably seen a lot of changes over the years
[1:56] and kind of provide perspective to people.
[2:01] Cause I feel like, you know,
[2:02] I've lived my own experiences in life,
[2:04] you know, being a patient, of course,
[2:08] of the health system, which we all are,
[2:10] you know, being a parent with kids
[2:13] that have medical issues, right?
[2:15] And then also being a professional that's a helper
[2:18] and also navigating like the business end
[2:20] of being a helper, a professional
[2:23] and, you know, being a business owner
[2:25] that's also taking care of a lot of other people,
[2:27] staff, community, all the stuff and holding a lot.
[2:31] So there's a lot behind the curtain,
[2:33] I feel like, potentially, right?
[2:36] Whether it's the administrative
[2:36] or really the physician part of it,
[2:39] I don't know if you would agree with this,
[2:41] I would say that you are,
[2:43] you represent a lot to parents and to kids
[2:47] when they come to Dr. Tolcher, right?
[2:50] It's a, there can be a lot of anxiety
[2:53] that comes with it.
[2:55] You have a kid that's unwell,
[2:57] even if it's something that a physician,
[3:00] through their lens, might be like,
[3:01] well, it's just a fill-in-the-blank, right?
[3:04] A parent, this is their most precious thing
[3:07] that they have in this world, right?
[3:09] They're scared, you represent a lot
[3:12] and how that interfaces with how life has changed
[3:15] our access to information, right?
[3:17] So that's kind of also why
[3:17] I kind of wanted to go through that,
[3:19] because like, what's that app now, Open Evidence?
[3:22] Open Evidence, it's an AI app that for clinicians,
[3:25] it's very powerful, I use it virtually every day,
[3:27] I like it.
[3:28] Yeah, which is awesome, so these tools are great
[3:30] and a lot of them, people have access to them
[3:32] and some of them are not as curated
[3:35] or how to say, guidelineed as an Open Evidence, right?
[3:39] The chat GPTs are before that,
[3:41] the web MDs are, what have you, right?
[3:43] So we have access to information, good or bad,
[3:46] but then the end of the day,
[3:48] when you have a sick kid, you go to Dr. Tolcher
[3:51] and that's, from my perspective,
[3:54] an emotional thing that you're taking care of
[3:56] alongside the science, right?
[3:59] So that's where I kind of was really interested
[4:01] in talking to you about the science, right?
[4:03] And where that provides comfort, like, okay,
[4:06] we can trust that we know what to do here
[4:08] and it's gonna be okay.
[4:09] And then what happens for you as a physician
[4:12] when we don't have that on our side, yet, maybe.
[4:17] And also the human side of sitting with people in distress,
[4:23] which I'm very, it's something that is my whole profession,
[4:28] essentially, and I think it's as big a part of yours,
[4:32] I imagine, but I wanted to have that conversation.
[4:35] I haven't had that opportunity,
[4:37] so thank you for being open to that.
[4:39] I don't know where we're gonna go.
[4:40] Absolutely, sounds like we got a few things we could cover.
[4:43] Yeah, yeah, so let me start with,
[4:45] like what got you into wanting to be a helper,
[4:47] wanting to be a physician
[4:49] and a pediatrician in particular?
[4:51] You know, I have memories of a very young child
[4:54] in Cleveland, Ohio, watching a TV program
[4:57] called Marcus Welby MD.
[4:59] And yes, I'm a little old, I guess,
[5:01] but he would do house calls.
[5:03] He had his little bag and everybody just respected him
[5:05] and I became a science and math guy.
[5:08] I was good at that.
[5:09] I liked it.
[5:10] I love science, but it has its limits
[5:11] and we can get into that.
[5:12] And then I just throughout my life,
[5:15] I just kept coming back to medicine, medicine, medicine.
[5:18] There was a time when I was in high school,
[5:19] I was a competitive speaker and debater.
[5:21] I traveled around the country
[5:22] and did pretty well, won a couple tournaments.
[5:24] So I thought I might want to be a lawyer.
[5:26] I kept coming back to medicine.
[5:28] So just that tug of the heart.
[5:30] And I went into medical school,
[5:32] thinking I was gonna be an adult cardiac surgeon
[5:35] and I came out thinking I was gonna be
[5:37] a pediatric cardiologist because I love cardiology.
[5:41] And then once I did my residency,
[5:43] I again followed the tug of the heart,
[5:45] which is, yeah, I love cardiology.
[5:47] I still do, but general pediatrics just did it for me.
[5:50] It charged me like nothing else did.
[5:52] So I decided to be a general pediatrician
[5:54] and I haven't looked back for 30 years.
[5:55] What do you think?
[5:56] And I would do it again.
[5:57] Sparked it.
[5:57] What was the spark you think that like said,
[5:59] I wanna do that, the general stuff.
[6:01] Being a pediatric, oh, general as opposed to specialty.
[6:03] You know, it's more of the whole child picture.
[6:06] And even what that has looked like
[6:08] has evolved in my career.
[6:09] It started off, you know,
[6:11] we were trained in the disease model
[6:13] of diagnosing, treating, preventive care was also discussed,
[6:16] but it was really not the focus of, to be honest,
[6:19] most of my training.
[6:20] And so now one of the joys of my life
[6:23] is kind of the wellness approach,
[6:24] where I really look at the entire child
[6:26] and not just what disease,
[6:27] can I diagnose what labs do they have?
[6:29] Do I need an X-ray?
[6:30] Do they need medicines to be,
[6:32] I've learned to be a better steward of medicines,
[6:34] especially antibiotics has been over my career.
[6:37] That's changed a lot.
[6:38] A lot, a lot.
[6:39] And my job is to be careful with those things
[6:41] and only use them when needed.
[6:42] And so I like operating in that space.
[6:45] And I've really,
[6:46] part of the reason we got to know each other
[6:47] is I've become very,
[6:49] I've seen the trends in mental health care in kids,
[6:51] where rising rates of anxiety and depression,
[6:54] but I think even more anxiety from what I see,
[6:57] supercharged by COVID,
[6:58] but even before COVID, it was on the rise.
[7:01] And along with that parental anxiety,
[7:03] and I think over the last 30 years,
[7:04] I just, I feel like I have,
[7:06] we always worry as parents, you said it already.
[7:08] I mean, our kids are, you know, part of us, right?
[7:11] No, when it's 9 p.m. and there's 104 fever,
[7:13] you get scared.
[7:15] 100%.
[7:15] And it's true that a lot of my job,
[7:17] if fortunately, one of the reasons I was drawn
[7:19] to pediatric space is that kids
[7:20] are by and large really resilient.
[7:22] And they don't get bad things very often.
[7:24] In adult medicine, you deal with a lot of end stage things.
[7:27] And I loved it, it was still fun,
[7:29] but PG had a chance to catch them earlier in life
[7:32] and prevent some of those things hopefully
[7:34] with that whole child wellness approach,
[7:36] not just diagnosing and treating diseases.
[7:38] So yeah, I've seen a lot of trends
[7:40] in the last 30 plus years.
[7:42] Yeah, there's a lot to go in there
[7:43] and we can certainly talk about COVID
[7:45] and the impact and stuff.
[7:46] And, you know, I'm gonna share a story with you
[7:49] if it's okay.
[7:50] Absolutely.
[7:50] From my personal background,
[7:52] again, I was, I've been reflecting
[7:53] on my personal journey with medicine.
[7:56] And, you know, my mother was diagnosed
[7:58] with a bad cancer when I was in middle school.
[8:03] And there was a Revlon breast center in UCLA.
[8:06] And that was the best at the time.
[8:09] Sure, it's still around.
[8:12] And there was a very well-respected doctor there
[8:17] and brilliant man and revolution,
[8:20] like he revolutionized the treatment and everything.
[8:24] So I was glad that she had the privilege
[8:27] of accessing someone like that.
[8:31] And he was not kind.
[8:34] So my mother was not kind to me.
[8:36] And that experience gave me a drive to be a physician.
[8:42] So that's where when I was an undergrad, I was pre-med.
[8:45] And I said, I'm gonna be both.
[8:48] I'm gonna be someone who, you know,
[8:50] is on the cutting edge that is, you know,
[8:52] has the mind for it,
[8:54] but is also going to pay attention to the physician.
[8:58] And this is an adolescent, essentially, me, mad,
[9:01] you know, pissed off.
[9:04] Now I have more perspective of like
[9:06] what it could be like to be someone like that.
[9:08] And some of the things
[9:10] that he probably had to deal with on a day-to-day basis
[9:14] and how he had to manage his own experience of that,
[9:19] you know, like my, I have a,
[9:20] my brother-in-law is an ER physician.
[9:23] And in some ways I think that really works for him.
[9:25] And I'm curious if it works for, you know,
[9:27] general peds works for you
[9:28] because you don't know what you're going to see today.
[9:31] And that for a certain type of mind
[9:33] is like really necessary, you know,
[9:35] rather than I'm gonna do the same surgery
[9:37] for 30 years and perfect it, you know,
[9:39] for other people that works really well,
[9:41] but it doesn't work for me, for instance.
[9:43] I like to do a lot of different things that stimulates me.
[9:46] So anyways, going back,
[9:48] I think that when my brother-in-law
[9:53] has to see death every day,
[9:56] he has to find a way to cope with that.
[9:58] So there has to be what an outsider
[10:00] may look at as a callousness
[10:02] or an attachment to these things
[10:05] that they're having a different experience of, of course,
[10:08] right, seeing their family member die or unwell.
[10:13] And yeah, peds, you're right.
[10:14] I think you get some,
[10:16] the majority of your cases are positive, right?
[10:19] And I imagine some of them aren't.
[10:21] So that's a lot there to unpack.
[10:24] And I'm just curious your thoughts about,
[10:26] because again, I get the sense that you all,
[10:29] you mean a lot to your, the families that you serve,
[10:32] like a lot, like you represent so much.
[10:34] And yet your doctor told you to them,
[10:36] but you're Chris, like you are human, you know?
[10:41] So with my own positives and negatives
[10:44] and struggles and personal story.
[10:46] And exactly, exactly right.
[10:48] Yeah, you said something that really hit home to me,
[10:53] which is one of the hardest lessons for us to learn,
[10:56] not on the clinical side,
[10:57] but on the human side and what I do
[10:59] is threading the needle between caring a lot.
[11:03] And caring, and yet not caring so much
[11:08] that you're emotionally devastated by badness.
[11:10] Like giving bad things.
[11:12] Yeah, I mean, there are times when I've cried along
[11:13] with families and it happened on even yesterday,
[11:16] I was in the office and a mom started to cry
[11:17] and offered her a tissue box.
[11:19] And I said, excuse me if I start getting it.
[11:20] So I'm human, right?
[11:22] And like-
[11:23] Hold on, but you allow yourself to be human.
[11:24] Yeah, and that took me a lot to learn that.
[11:27] I mean, for a while it's like you want to be tough.
[11:30] So there's, we all bring our own personalities
[11:32] to our roles, right?
[11:34] And our stories, our life experiences
[11:36] for what has made life challenging
[11:39] and also glorious at the same time.
[11:43] But I guess what I'm trying to say is that we have to,
[11:46] we're helpers, we have to be caring.
[11:48] And I think pretty much everybody
[11:51] that goes into medicine is a caring person.
[11:53] But we bring our personalities and our styles
[11:55] and what we learn along the way.
[11:56] And some people that shared experience,
[12:01] that empathy that you have with others
[12:03] can lead you to a place where you've got your own issues
[12:06] and you kind of put your wall up, right?
[12:08] And the wall can come across as callousness
[12:11] or hard personality or not caring.
[12:14] But in reality, there's probably a backstory to that, right?
[12:18] So my, what I've discovered over 30 years
[12:20] is I am now okay showing emotion in front of families.
[12:23] It took me a while to learn that.
[12:24] And I think they appreciate it.
[12:26] I think they know that that shows my humanity.
[12:28] And it shows that when our kids hurt, we hurt.
[12:32] And I feel a similar thing in the office.
[12:35] And you probably, I'm sure you feel it
[12:36] when you talk to really struggling.
[12:37] I remember one time I was in personal story
[12:40] in therapy for a while, I was going through a rough time
[12:41] and I told some painful stories
[12:43] and my therapist cried right along with me.
[12:45] And it almost makes me,
[12:46] thinking about it gets me emotional,
[12:48] but that meant a lot to me.
[12:50] And so I am okay showing emotion,
[12:52] but I can't let it cloud my judgment.
[12:53] And this is where the rubber hits the road.
[12:55] You have to care to the point,
[12:57] you're caring a lot where you're willing to,
[12:59] like when I don't know something,
[13:00] I'm going home and looking it up.
[13:01] I mean, I'm a perfectionist at heart,
[13:04] but I also have to know my limits, watch myself.
[13:07] Sometimes I need care too.
[13:09] Sometimes the helpers need help, right?
[13:11] And we all know that.
[13:12] And we're not always the best at asking for it.
[13:14] But so yeah, I think it is a tough line to walk,
[13:20] but and I still struggle with it.
[13:22] But I do, I care a lot about everybody in front of me
[13:26] and I hope that it shows.
[13:29] But yeah, I also have to be objective.
[13:31] And I think that, yeah.
[13:33] Yeah, and I love where we're going with this,
[13:36] but there's a, again, a duality,
[13:38] a Dr. Tolcher and a Chris,
[13:39] or there's a Dr. Blake and a Blake.
[13:41] You know, there's, you have to hold both.
[13:45] And that's what's difficult.
[13:46] And when you lose track of either one
[13:48] is when we can go sideways, right?
[13:50] In any kind of way,
[13:51] whether it's the care or that trust
[13:54] that is so needed, you know,
[13:57] people need to feel, I think,
[14:00] that they're with someone that sees them,
[14:01] you know, as a human.
[14:03] And that's where it sounds like you've developed that,
[14:05] that ability to be vulnerable and that willingness
[14:07] or that maybe that you at some point
[14:11] on your journey as a physician
[14:14] saw the necessity of that
[14:16] or saw that that was something that would be beneficial.
[14:19] And I'm curious,
[14:20] because, you know, I didn't finish my journey
[14:23] to go to med school for reasons.
[14:26] And I have a concept of what it's like
[14:28] and I didn't do it, so you did it.
[14:33] And I know, I think I know,
[14:36] that we train our physicians in a certain way, right?
[14:40] And in a way that produces
[14:42] a lot of public health results in a good way.
[14:46] We have limited resources to serve the whole population,
[14:51] right?
[14:52] And I'm curious about reflecting for you
[14:54] on what you were like coming out of med school
[14:58] and where you are now and what kind of got you there
[15:00] in this kind of a way.
[15:01] And like straddling the human Chris and the doctor, Chris,
[15:05] you know, objectivity, science-driven,
[15:08] results-driven person
[15:10] that that's what your main job description is, right?
[15:15] And like the steward of hope for families and containment.
[15:21] I think one of the benefits of, I'll call it wisdom,
[15:24] over the last 30 years, you could say age,
[15:27] is I have a perspective that I didn't have
[15:30] when I started coming out,
[15:31] when I first came out of med school in a few ways.
[15:34] One of which is there's a saying, you know,
[15:35] kids don't follow the textbooks, right?
[15:37] We don't follow the textbooks.
[15:38] We learn book knowledge theoretical,
[15:41] you've got this knowledge base,
[15:42] and then the real world hits.
[15:44] And not only that, coming from residency
[15:45] to private practice is a huge change.
[15:48] I spent four years at Children's Hospital in LA
[15:50] as a resident and chief of the residence
[15:52] where I taught for a year, and I learned a ton.
[15:54] And I saw a lot of families and kids
[15:57] going through some very hard times.
[15:59] Can you see everything there?
[16:00] It was incredible training.
[16:03] And I came out thinking every child had a bad disease
[16:06] to exaggerate to make a point.
[16:08] So early in my career, I was working things up.
[16:10] We call it working up.
[16:11] Like I had in my mind what the bad thing could have been.
[16:14] And my job was to exclude the bad things
[16:16] and then deal with the not so bad, right?
[16:18] So I did a lot more testing early in my career
[16:21] because I didn't want to miss those bad things.
[16:23] Now, what makes me a good doctor today,
[16:25] better doctor today, I think,
[16:27] is that I have better judgment on when to do those tests,
[16:31] but I still have the knowledge
[16:32] of when the bad things might be.
[16:34] And so, I'll tell the parent,
[16:35] look, I don't think this is X.
[16:38] We're all afraid of our kids having brain cancer
[16:39] and leukemia to use two examples, right?
[16:42] Headaches equals brain cancer in a lot of our minds
[16:44] and body aches and fatigue equals leukemia.
[16:47] I deal with that conversation a lot.
[16:49] And so, I have to make sure we're not missing that.
[16:53] And there was a case earlier in my career
[16:55] where I did miss it.
[16:55] It was a very hard case.
[16:57] And to this day, I still think about this person
[16:59] where the labs didn't show it
[17:02] and I was being led in a different direction.
[17:04] So, but I now know better when I need to do the labs
[17:09] and when I can reassure.
[17:10] And there are times when I have to say,
[17:12] Blake, I don't think your child has X.
[17:16] Is there a small chance?
[17:18] Maybe let's rule out that small chance, do these labors.
[17:20] But I want to reassure you
[17:21] that I'll be surprised if they come back.
[17:22] So, I try to cover the bases, not reassure.
[17:26] Sometimes when you over test, you worry people more.
[17:29] Because now he thinks something's wrong.
[17:30] Well, the full body MRI, right?
[17:32] That's like, it will find something.
[17:34] Kids with chronic pain is an example of that.
[17:36] There's a lot of chronic pain syndromes out there
[17:38] where there's valid reason to have pain,
[17:40] but then there's other areas where the more you test,
[17:42] there can be like a whole child component behind that,
[17:47] including mental health that feeds into it, right?
[17:50] And if I overdo the testing,
[17:51] I reinforce the thought that something's wrong with me.
[17:54] So, I have to thread that needle, right?
[17:56] So, I've gotten better at threading the needle, I think.
[17:58] I'm still learning, science is all,
[18:00] we have to be open to new things.
[18:02] Anybody that tells you science is subtle
[18:05] doesn't understand science,
[18:06] unless they're talking about maybe the law of gravity.
[18:08] Well, I think that that's again perspective, right?
[18:12] Like I've also had some experience with academia, right?
[18:15] And doing research,
[18:17] and also understanding that there's limitations
[18:19] to what gets researched,
[18:21] what is replicable in a trial, those kind of things, right?
[18:26] Who's funding those things,
[18:27] which is not to cast it in negative light,
[18:33] just knowing that it has limitations, right?
[18:35] So, if we only look at-
[18:36] So, a powerful tool.
[18:37] Yeah, very powerful tool and a necessary tool
[18:39] and a good tool.
[18:40] So, it's not to say it's bad, it's just limited.
[18:43] Doesn't have all the answers.
[18:44] Correct.
[18:44] I mean, one of my favorite sayings is,
[18:46] and it's a little silly, but it's true.
[18:48] Science only knows what it knows
[18:49] and sometimes it doesn't know what it doesn't know
[18:51] and that means the body of knowledge is what it is.
[18:53] As a, I'm a scientist at heart, I studied science.
[18:57] Medicine has a solid science foundation,
[18:59] but it has its limits.
[19:00] And as what I do as a,
[19:02] I guess we'll call a Western medical doctor,
[19:04] not Eastern and not,
[19:05] there's a lot of other areas of healthcare
[19:07] like functional medicine and acupuncture
[19:10] and Ayurvedic medicine that are complimentary to what I do.
[19:13] And I'm not an expert on those, but I respect them
[19:16] and I think they can pick up where I,
[19:17] my training leaves off in many ways.
[19:19] Yeah, because many people,
[19:21] the Western medicine hasn't yet caught up to their disease.
[19:26] So then people look for answers
[19:27] and that's also a scary place
[19:30] because you do want to have,
[19:33] well, this is, this will work, right?
[19:34] And a lot of those functional medicine stuff,
[19:37] there's a faith almost, a belief that also has to be there
[19:41] rather than just the empirical evidence.
[19:43] 100%.
[19:43] This is going to work and everything.
[19:47] Cool, well, again, I wanted to acknowledge,
[19:49] thank you for being vulnerable.
[19:50] This is awesome to hear and share this space with you.
[19:56] Going back to like the idea that
[19:59] we don't always have the answer.
[20:01] Like when we, you know, in our practice,
[20:04] we also work with,
[20:05] well, we work with pretty acute individuals, right?
[20:08] Youth that are suicidal or maybe have had an attempt.
[20:12] You know, we revert comfort in our ability to treat, right?
[20:17] And at the same time,
[20:19] we're holding the other side of that,
[20:21] which is like, we can't fix.
[20:23] Like there is no fix.
[20:25] Like we're going to help them grow.
[20:26] We're going to teach them some skills.
[20:29] We're going to, you know,
[20:30] try to hold a container for them.
[20:32] I guess speaking to that idea of science
[20:35] and how it's amazing,
[20:37] when that runs out of road,
[20:40] you know, for you as a physician,
[20:43] where, you know,
[20:46] I mean, my own examples, I have multiple sclerosis.
[20:48] So there's not unfortunately a ton in Western medicine
[20:51] that is definitively helpful for me.
[20:54] So I look for other things, right?
[20:56] But I have to be held by a neurologist
[20:58] that can't fully fix the problem.
[21:01] Can't cure it.
[21:03] How is that for you as a human,
[21:06] you know, in your office on the day-to-day when,
[21:09] you know, there is something going on.
[21:12] Or there's a possibility of something going on.
[21:14] That's another threat that I want to kind of put a pin in,
[21:17] like that 1% chance, right?
[21:18] Which I, but to go on this route,
[21:22] like how is that for you as a human to hold that?
[21:27] That I can't fix.
[21:28] That the scientist in you, you know,
[21:29] sometimes it's like, you know, you have a fever.
[21:31] I can, I know how to fix that.
[21:32] You have this disease that's antibiotic for it.
[21:36] That's not always the case.
[21:38] Some things for me are easy and easy to fix.
[21:41] And your infection, here's your amoxicillin, right?
[21:44] Here's your rash, here's your cream for it.
[21:46] So those are the easy parts of my job.
[21:50] The tough parts are either the significant health issues,
[21:53] the struggles, the things that I may not know
[21:54] what's going on sometimes.
[21:56] So the diagnostic dilemmas,
[21:58] which the scientist in me thrives on, I love.
[22:00] I'm kind of a detective in a way.
[22:02] I like looking for the cause.
[22:03] And I think I'm pretty good at it,
[22:05] although I have to know my limits.
[22:07] And if I can't find the cause,
[22:08] I have to refer you on to somebody who can,
[22:10] like a specialist, right?
[22:13] It's the harder, harder cases are the children and teens
[22:17] with either bad diseases or in the case of, you know,
[22:21] mental health, bad diseases, for example,
[22:23] or bad illnesses, bad conditions
[22:24] where we can only smooth the road.
[22:28] Yes.
[22:29] Make the, make the lows less low.
[22:31] Make the bad highs less high and make the swing less,
[22:34] but we can help them manage it,
[22:35] improve their functioning in life,
[22:37] like the functional approach,
[22:38] rather than the curative approach.
[22:40] And that's true of a lot of conditions, right?
[22:42] And I think that's part of the human condition.
[22:46] So the human in me says, I know that that's
[22:47] a part of life, that there are things
[22:48] that we just can't fix,
[22:49] either because they don't have a fix
[22:51] or we just haven't figured it out yet.
[22:53] Or maybe someone else has the fix that I don't.
[22:55] And so this is where I think knowing the limits
[22:57] of my type of healthcare,
[22:59] the type of helper that I am,
[23:01] it's traditional Western medicine.
[23:02] And even though I'm fascinated by the non-Western medical space,
[23:08] I read about functional and integrative medicine a lot.
[23:11] I'm fascinated by it.
[23:12] And I see that as like kind of evidence in form,
[23:15] but maybe not as evidence based as what I do.
[23:17] Meaning there's evidence for it,
[23:18] but it's not the gold standard,
[23:20] double blind, placebo controlled trial.
[23:22] Does that mean it's wrong?
[23:23] No, maybe the evidence just isn't there yet.
[23:25] Not everything is amenable
[23:26] to that kind of studying and testing.
[23:28] So as a quick example, I'm fascinated by it.
[23:30] And I know a lot, there's a growing use of it.
[23:33] So it's here, it's got a good purpose.
[23:35] And there are times when it clashes with my recommendations
[23:38] and I have those conversations with families.
[23:41] So, but I'm open to learning.
[23:42] I mean, I'm a learner at heart, right?
[23:43] Scientists have to be open to learning.
[23:45] And so I think that I have to get comfortable
[23:49] in the space that I can't fix everything.
[23:51] And I am, even though it still hurts.
[23:53] Yeah, yeah, so to hold that.
[23:55] And going back to that,
[23:56] you said something that struck me,
[23:58] which struck a chord in me, which I'm very aware of.
[24:00] And that's kind of the comment I made about public health,
[24:03] like you're serving the greater good
[24:04] and you only have so many tests around,
[24:06] so many resources of time, money, insurance,
[24:11] interface with insurance companies,
[24:15] that there's a 99% chance
[24:17] that whatever the parent is worried about,
[24:20] it's not that, right?
[24:22] And that's, you're pretty sure.
[24:23] Like you have a lot of experience,
[24:25] decades of experience with families and kids.
[24:28] And you're pretty sure, but there's a 1% chance
[24:30] that that's true.
[24:31] And you've experienced that too,
[24:33] where it was missed, right?
[24:34] And that was pretty devastating.
[24:37] And actually just to the side,
[24:39] do you know Dr. Dan Siegel at all?
[24:41] Have you heard of him?
[24:43] So he's a physician, I believe, at UCLA.
[24:49] And he's written a number of amazing seminal books
[24:51] on parenting in particular.
[24:54] I should get to know Dr. Siegel.
[24:55] He's, yes, he's amazing.
[24:57] He's a good speaker, author, researcher.
[25:00] And he wrote a book about adolescence
[25:02] called Brainstorm, something like that.
[25:07] In the show notes, correct that.
[25:09] But he talked about, you know,
[25:11] adolescence in general, there's a general,
[25:14] you know, misnomer that they are irrational
[25:17] in their decision making.
[25:20] And he coined a term called,
[25:22] no, they're not irrational, they're hyper-rational.
[25:25] So when, you know, an adolescent, for instance,
[25:30] is making the decision to joyride
[25:33] in their parents' minivan at 2 a.m.,
[25:37] the parent freaks out.
[25:39] And, you know, they don't have their permit yet.
[25:41] That's dangerous, they could be hurt, you know,
[25:43] all these things.
[25:44] So that's an irrational decision.
[25:46] And Dr. Siegel would say,
[25:48] well, no, they're hyper-rational.
[25:49] They're saying, well, you know, it's 2 a.m.,
[25:52] there's no one on the road.
[25:55] No one's going to even pay attention
[25:57] because they're going to be asleep.
[25:58] So there's a 99% chance that I'll go and come
[26:02] and it'll be fine.
[26:03] And by the way, the payoff is novelty, right?
[26:05] So for an adolescent, that's fun.
[26:06] If you ask me to do that, I'd be like,
[26:08] I'm good, I want to sleep.
[26:10] Going the freeway at 2 a.m. in a minivan
[26:12] is not my form of excitement.
[26:14] But it is for them, right?
[26:15] So the payoff is big.
[26:17] And chances are, they would be okay, right?
[26:20] And what Dr. Siegel would say is,
[26:21] yeah, but an adult is more keyed into,
[26:25] well, that 1% chance of something bad happening is bad.
[26:28] That's really bad.
[26:30] Maybe financially for their safety, all the things, right?
[26:34] So his argument was that, no, it's not irrational,
[26:37] it's hyper-rational.
[26:38] And I always wondered if that's something
[26:42] that our medical system and how we train physicians
[26:46] in the public health way, which again is necessary,
[26:50] that's the outcome sometimes,
[26:53] of almost thinking in a hyper-rational way.
[26:57] No, it's 99% chance, so I'm not gonna do the test.
[27:02] Yeah, I think there's truth to that.
[27:04] Haven't really maybe looked at it
[27:06] from that angle of hyper-rationality.
[27:08] When I hear you explain that, to me,
[27:11] it almost means like,
[27:12] there's a bit of risk tolerance thrown in there.
[27:15] When we're younger, the classic child and adolescent
[27:18] is more risk-taking.
[27:20] And chances are it's not gonna happen to me,
[27:22] so I'm gonna jump off that cliff
[27:23] and I'll probably be fine, hit in the water,
[27:25] or doing something that we might go,
[27:27] why did you do that, right?
[27:28] And as we get older, a lot of us become more risk-averse
[27:32] and those little what-ifs will stop us in our tracks.
[27:35] And then what I do, like when I'm facing a situation
[27:38] in the office with, let's say,
[27:40] I have a child with recurring fevers,
[27:42] and 99% chance it's gonna be something benign,
[27:45] like they just get sick a lot,
[27:46] they catch a lot of viruses,
[27:47] they're in preschool, whatever.
[27:48] But there's that 1% chance
[27:49] that there's another cause that I can't tell, right?
[27:52] So I have a decision to make.
[27:53] We've all got, part of the irrational, irrational thing,
[27:56] I think is the algorithms in our head
[27:57] for getting on certain paths,
[27:59] and okay, this leads me down this path,
[28:01] but you might miss the data
[28:02] in the other side of the algorithm, right?
[28:04] So your decisions don't always end up
[28:06] being the best ones.
[28:07] But in my mind, what I have to do,
[28:09] okay, there's always a 1% or a 0.5%
[28:13] or that this headache could be tumor, right?
[28:15] So does that mean I MRI every child
[28:17] with a headache? Of course not.
[28:18] So I then have to like, in some ways I'm a detective,
[28:21] I'm looking for clues, we call them red flags
[28:23] and I feel reasons that I do need to do the MRI
[28:25] or reasons that I do need to do the blood test.
[28:27] And if I see those, I go, right?
[28:28] I don't assume that it's probably nothing.
[28:32] The other part of the calculation is
[28:33] how bad is it if I missed that 1% chance today?
[28:37] There's a time factor there.
[28:39] A lot of these things will play out.
[28:40] If I miss something, which we all do
[28:42] as smart as I think I am,
[28:44] I'm not batting 1,000 as a doctor.
[28:46] I hope I'm batting close,
[28:47] so that if I missed that 1%,
[28:50] will it declare itself over the next few days or weeks
[28:53] and then I can pick it up
[28:53] and the child's still gonna be fine.
[28:55] So that's factored in, too.
[28:59] Yeah, so I think that there is,
[29:01] and we docs are different in how risk,
[29:03] you can go to five different docs
[29:04] and some will do the test, some won't.
[29:06] Some will say it's this, some will say it's that.
[29:08] It's not all cookbook science.
[29:10] We are science-based, evidence-based,
[29:13] but there's a limit to our evidence
[29:14] and then we get to use our judgment and our experience.
[29:17] And that's where I hope my wisdom
[29:18] makes me better than I was 30 years ago.
[29:21] Sure, yeah, I hope.
[29:23] And I think you probably are.
[29:25] I hope so and I hope so.
[29:26] And you mentioned algorithm, and I get that.
[29:30] Like you're holding so much in your mind, right?
[29:32] With like, am I gonna do this test, am I not?
[29:34] Is it worth?
[29:34] And you said, am I gonna MRI every kid?
[29:37] No, right?
[29:38] And I know you have the backstory
[29:41] to what makes you to say that, right?
[29:44] And I can guess, I mean, cost and exposing kids
[29:48] to potentially dramatic things or whatever.
[29:51] What is behind that when you say?
[29:52] Why not MRI every child with that?
[29:54] That's a great question.
[29:55] I mean, this is where the big picture view comes in.
[30:00] There's public health aspects to this.
[30:02] Another example is I just had this conversation
[30:03] yesterday with her.
[30:04] When I go to the doctor, I get lab work every year.
[30:07] Why do you never order blood work on my child?
[30:09] Same conversation in a sense,
[30:11] but one's preventative and one's following a symptom.
[30:15] So yes, cost.
[30:16] I mean, we have limited resources, you said it earlier.
[30:18] I mean, MRIs are expensive.
[30:20] That's one big part of this.
[30:22] I have to be a steward of those resources, right?
[30:24] And I have to use the right judgment
[30:26] to not overspend, overtest, overprescribe,
[30:29] over manage all that stuff.
[30:31] So, but there are times when that's worth it.
[30:34] Like missing that is a big deal
[30:35] to that child and that family.
[30:37] And sometimes I have to order the test
[30:38] even though I don't think they need it,
[30:39] but the family needs it.
[30:41] Okay, same, yeah, I was gonna go there.
[30:42] Right, which means I can give all,
[30:44] this happens often.
[30:45] I can use my best judgment,
[30:47] but that 1%, if that's gonna keep you up awake,
[30:50] keep you awake at night worrying about your child,
[30:53] and I can't reassure you.
[30:55] And also, maybe now I want the 100% reassurance.
[30:58] So that I know that you're not gonna invest,
[31:00] you know what, I knew in my heart
[31:01] something was wrong and the doctor told you missed it.
[31:03] And it's not just, okay, yeah, our ego's involved.
[31:06] We don't like missing things.
[31:06] I'm gonna be real with you.
[31:07] I don't like making mistakes because it hurts me.
[31:11] And it keeps me awake.
[31:12] Well, you keep thinking about that one kid.
[31:13] You know, that's when I lose sleep.
[31:15] I mean, I know when I talk to kids about anxiety,
[31:16] I've got my own anxieties, right?
[31:18] So, and some of it makes me a really good doctor
[31:21] because I don't wanna miss things.
[31:22] There's a good aspect of anxiety,
[31:23] which we don't talk enough about,
[31:24] but then when it crosses the line.
[31:25] So I guess what I'm getting to
[31:27] is that I have to be a steward of the resources, yes.
[31:31] I also have to be aware,
[31:33] and I made the comment a bit earlier,
[31:34] when you over test,
[31:35] you sometimes contribute to anxiety,
[31:36] not helping anxiety.
[31:37] And the last comment is that if I did blood work
[31:40] on every child every year,
[31:42] what happens is, and let's say these are well kids,
[31:45] there's not a reason to do it, okay?
[31:47] The odds of me finding something that's serious
[31:50] is super low.
[31:51] It's down around 1% or less.
[31:53] What's much more likely to happen is
[31:55] when we all get lab work,
[31:56] a few of the values are a little bit off.
[31:58] It's almost never 100%,
[32:00] a little bit high, a little bit low,
[32:02] because they bounce around in a range.
[32:04] And if you catch it on that,
[32:04] now I'm in the rabbit hole
[32:06] of having to do other follow-up tests
[32:08] to reassure the parents that one point above normal
[32:11] that's gonna keep them up at night, you follow me?
[32:14] So it becomes the rabbit hole of over testing.
[32:16] That's another reason.
[32:16] And you brought something up,
[32:18] word came into my mind as intuition,
[32:21] like mother's intuition, father's intuition,
[32:24] your own intuition, right?
[32:26] Which is not science, that's a gut thing.
[32:28] And that's from,
[32:29] there's something different about my kid.
[32:31] My kid has changed, right?
[32:33] Where does that for you factor in?
[32:35] Because it sounds like you do know.
[32:37] No, I'm saying I love the question.
[32:38] I'm going, yeah, let's go here.
[32:39] Okay, because I'm like,
[32:40] it seems like you do pay attention to that.
[32:42] Good one.
[32:43] Okay, I get the sense that you,
[32:45] and I think that is what is,
[32:47] either gets lost or sometimes even
[32:54] devalued.
[32:56] And where does that lie in it for you?
[32:59] Because again, it sounds like,
[33:00] yes, the basis is science,
[33:02] the basis is your knowledge, your experience, right?
[33:04] And then there's this other part
[33:05] that sometimes gets influenced
[33:06] or maybe always to its extent,
[33:09] it's an influence, which is intuition.
[33:11] So where does that play?
[33:13] So science is a powerful way of knowing things,
[33:15] but it's not the only way to know things.
[33:16] Sorry, that's the,
[33:17] but what you just said triggered something for me
[33:20] that I often tell the story that I learned
[33:22] when sometimes the feedback I get from parents
[33:24] is they appreciate me
[33:25] that I actually sit in a chair and listen to them.
[33:28] In fact, there was a doctor
[33:29] who one of the fun quotes in medicine was,
[33:31] the most important and powerful medical invention
[33:34] for doctors to use is the stool
[33:37] for you to sit in and take a history.
[33:39] We call it taking a history of listening to people.
[33:41] Look them in the eye,
[33:42] which is why I don't like head and a computer.
[33:44] And so anyway, and my mother taught me,
[33:46] listen to mothers.
[33:47] So listen to parents.
[33:49] I always say, you're the expert on your child.
[33:51] I might be an expert in pediatrics,
[33:52] but you're the expert on your child.
[33:54] And if you're worried about something,
[33:55] I need to make sure I'm not worried about it.
[33:57] And if I am, I need to say,
[33:59] look, I'm concerned about this.
[34:00] Here's what we're gonna do.
[34:01] And if I'm not, I'm gonna say, Blake, I get it.
[34:04] You're a parent.
[34:05] I worry about my kids too.
[34:07] And here's why I'm not worried.
[34:08] And then I like to answer the question.
[34:10] They don't ask me, when would you get worried, Doc?
[34:13] So I pretty much end most conversations
[34:14] was here's what I want you to take home and look for.
[34:17] Because we've got our algorithms.
[34:19] I don't use the algorithm word,
[34:20] but in my head, I've got a decision tree I'm using.
[34:22] And if I'm hearing red flags that make me go down
[34:25] a path where I want to look for something bad,
[34:27] I'm going for it.
[34:28] I'm not gonna say, oh, he's probably fine.
[34:30] But if I'm reassured, I'm reassured.
[34:31] And I don't want to over test.
[34:32] But if you give me more data that changes my mind,
[34:35] I might change my path.
[34:37] So I want to know if his fevers last more than five days.
[34:40] I want to know if this pain doesn't go away in two weeks.
[34:43] I want to know if my advice is not helping
[34:44] over the next four or five days.
[34:46] I have to end on that and give them something.
[34:49] Yes, I've given them reassurance,
[34:51] but there's still that what if.
[34:52] What if Dr. Tolcher is missing something?
[34:55] Yeah, that's what anxiety does for us.
[34:57] Yeah.
[34:57] So I'm gonna go back and reference a comment I made earlier
[35:01] about my own experience of a physician
[35:05] with my mother's care, who I said was brilliant.
[35:08] And clearly you're freaking brilliant.
[35:10] I mean, clearly you have, no, you can take it.
[35:13] So the algorithm is good.
[35:15] It's a good one.
[35:16] This decision tree, the knowledge,
[35:18] the thirst to continue to learn.
[35:20] I mean, all that stuff is what I would want my kid
[35:23] to have as far as, even to reassure me,
[35:25] like, you know what, Blake, it's okay, right?
[35:29] That being said, that reassurance feels different
[35:33] when it's from the top down versus that stool.
[35:39] To me, that feels important, that you sit on a stool
[35:43] and you're like same level.
[35:45] Look him in the eye.
[35:46] Look him in the eye and be like, I see you, I hear you.
[35:49] And you have some ability of permeating
[35:54] some of that experience of like touching that,
[35:57] your own being a dad, your own experience being a dad
[36:00] and maybe allowing yourself to feel that enough
[36:03] to inform how you interact with them
[36:07] and not overwhelm you, although at times it does,
[36:10] it just hits the threshold and we cry.
[36:13] We are in with them, right?
[36:15] That being said, we can't, right?
[36:17] So there has to be some way to manage that.
[36:22] So thank you for that.
[36:23] I think that's important for all of us helpers
[36:26] to know that piece, that we're not the expert
[36:29] and when we act as one initially,
[36:32] we tend to lose people.
[36:36] So kudos, that's, I'm grateful to hear that that's how you,
[36:41] you have found your way too.
[36:45] So kind of the last thing that I kind of,
[36:47] I mean, I'm in mental health obviously
[36:48] and we, you know, talk to you guys a lot
[36:53] and at Parkway Pediatrics
[36:55] and trying to help families together.
[36:59] We are professionals at this.
[37:00] This is what it's a graduate school for
[37:02] and all that stuff.
[37:02] And I kind of made mention of like,
[37:04] while we're confident, solely confident in our abilities,
[37:08] we know we can only do as much as we can, right?
[37:10] And there's, to that point is, you know,
[37:12] as much as I know, the more I know,
[37:14] the more I know I don't know everything, right?
[37:17] Yeah, so I have a PhD in this or whatever, but like,
[37:20] it's, it's an ocean that you can never get to the
[37:22] bottom of in terms of knowledge.
[37:24] Yes, exactly.
[37:25] So we'll keep trying.
[37:27] That being said, we will have cases,
[37:29] we will have people that hit the edge of that.
[37:33] You, I see as, and you mean a pediatrician in general, right?
[37:38] We get people when they've been identified,
[37:40] we get people that are when they're willing enough
[37:42] to reach out for help,
[37:44] which is, I know, a percentage of people that need it,
[37:50] percentage of people that can access it.
[37:53] So the front lines are emergency rooms are,
[37:57] you know, general physicians are pediatrics.
[38:01] You're again, Dr. Tolcher, the master of everything,
[38:05] including behavioral health.
[38:08] Can you speak to like what that's like to be something
[38:12] that even the specialists are, there's limitations, right?
[38:17] And now you are, you are like the front line
[38:19] and sometimes for a lot of people, the one,
[38:21] you know, to support that.
[38:23] You know, when I was, when I think about my job,
[38:27] my career, my job satisfaction,
[38:29] I keep coming back to gratitude
[38:32] that I have for being in a privileged space,
[38:35] privileged place with these families.
[38:36] And so thank you.
[38:38] The fact that they trust me
[38:40] or hopefully I earn their trust.
[38:42] And I consider myself kind of the gatekeeper,
[38:44] the quarterback of the medical team.
[38:46] So I'm kind of maybe often the first one they come to
[38:48] and then I get to decide,
[38:49] is this something I can manage or you need more, right?
[38:52] And so I think it is an amazing place to be.
[38:58] I think that in the mental health space,
[39:01] I think that I made a comment earlier
[39:02] that over the last 30 years,
[39:03] I've seen so many more today,
[39:07] mental health struggles in kids and teens
[39:10] than I did 30 years ago.
[39:12] And it's multifactorial as you know.
[39:14] But it's really given me the even more of a need
[39:21] to wanna focus on the whole child.
[39:23] And not just organ systems, diseases, vaccinations,
[39:27] which is a hotter subject now
[39:28] than it has been in the 30 years in Korea.
[39:30] I spent a lot of time talking about it.
[39:32] We can chat about that if you want to,
[39:33] but maybe wanna focus on the more personal side.
[39:36] But I think that my job is to be a focus on the whole child
[39:44] and really to screen them.
[39:46] That's the fancy word,
[39:47] we screen for the elemental issues and growth issues
[39:50] and diseases and especially in the mental health space.
[39:53] So I do consider and a lot of kids come to me
[39:56] with physical complaints that turn out to be anxiety,
[39:59] your depression, that's very common.
[40:01] As you know, right, headaches and tummy aches
[40:02] and I don't feel well and I'm tired
[40:03] and I feel like I can't breathe and all that, right?
[40:07] This hurts and that hurts.
[40:07] So there's a lot of that.
[40:08] And it's, and so you're right.
[40:10] I think that I see as a frontline helper,
[40:14] a responder for these families.
[40:16] Most of it I can filter out and manage myself
[40:18] because it isn't that serious.
[40:19] And I kind of triage them in my mind.
[40:21] Is it mild, medium or bad?
[40:23] Mild ones I can almost always deal with myself.
[40:25] The medium ones I can deal with a lot myself
[40:27] but maybe now you need to meet with somebody
[40:29] and talk through, learn some tips and tricks
[40:30] for how to manage the anxiety and the depression.
[40:33] And then the more severe ones I often have to refer out.
[40:36] That's kind of a simple way that I look at it.
[40:38] But I am in a privileged place I think
[40:42] and I'm so grateful for it that families trust me
[40:44] with that and it's really, it motivates me every day.
[40:48] I mean, I think we've kind of circled the question, right?
[40:51] I like what brought you to your field, you know,
[40:55] and you had showed with with me that you're from the Midwest,
[40:59] right? You're from Cleveland until 13, right?
[41:03] And that you kind of said you were a scientist at heart
[41:06] and wanted to pursue cardiology, right?
[41:10] And then in your residency, which happens, right?
[41:13] People get a taste of whatever they think they want to do.
[41:16] And then they get another taste and you're like, no, this is actually,
[41:19] which is actually kind of, I don't know if you have
[41:22] cold gratitude for that, but that doesn't always happen.
[41:26] You know, I've talked to many physicians, not many,
[41:28] some physicians who like what brought you to do this?
[41:31] And they're like, well, I wasn't good at the other ones,
[41:35] you know, or I didn't like the other ones.
[41:36] And it wasn't like I liked this one.
[41:38] A lot of elimination rather than the tug of the heart.
[41:40] Right. So that tug of the heart, I'm just curious to kind of
[41:44] maybe dig a little deeper into that, like what you think was the tug.
[41:48] I know you mentioned there were some cases that happened.
[41:52] Yeah. So pediatrics drew me because I love kids and families
[41:57] and I wanted to make a difference long term.
[42:00] I think part of working in that space, and I was talking about earlier,
[42:05] managing the emotional side of it, the human side of it
[42:08] and not being afraid to show it and making it
[42:11] making it help allowing it to help me be a better
[42:15] whole child wellness provider rather than a diagnostician
[42:20] of diagnosing and treating diseases.
[42:22] I think that my lived experience as a child.
[42:26] I mean, I grew up in, honestly, a rough part of Cleveland.
[42:30] It's there were gangs in the streets.
[42:31] One of my I don't talk about this much,
[42:33] but it's one of my I was probably nine years old.
[42:36] And one of I lived grew up on the west side of Cleveland.
[42:38] And it was just all I knew, right?
[42:41] And all my parents, they grew up there, too.
[42:43] And so one of my friend's sisters was shot in a drive by shooting
[42:47] at the age of when he was nine and I was nine or 10.
[42:50] And I was like, oh, my gosh.
[42:51] And so and so I saw a lot.
[42:53] And then and then I, you know, my parents divorced when I was 13.
[43:00] Sorry, when I was 16, that was had a huge impact on
[43:04] it rocks your world when that happens, right?
[43:06] And so so and then I was always a kind of a brainiac,
[43:10] you know, kind of a nerd.
[43:12] I'll say a proud nerd, love science, love math, just.
[43:15] And I was kind of a really, really a perfectionist,
[43:18] which is as pros and cons.
[43:21] So it just really made me driven.
[43:24] And I felt grateful to get out of the neighborhood
[43:27] that I grew up in at the age of 13.
[43:30] And then I've had my own pains in life, my own rough road.
[43:35] I've struggled. I've suffered.
[43:37] I've been in therapy in the past sometimes.
[43:39] Luckily, it's been a while, but so I'm human, too.
[43:41] Right. Yeah.
[43:42] And and I think that in some ways, those pains in life.
[43:46] And I see this as a pediatrician.
[43:48] Those pains in life build resilience.
[43:51] Yeah. If if they make you stronger and not bitter, right?
[43:54] That's the challenges, you know.
[43:55] And so I think that having, you know, resilience
[43:58] is a fascinating topic to me.
[44:00] And then we all work in the resilience space.
[44:02] Like, how do you build that?
[44:03] And what gave you that?
[44:04] Like you had some some adverse experiences, right?
[44:08] Absolutely. Which can go many different ways.
[44:11] Right? Yeah.
[44:12] You know, you mentioned perfectionism
[44:13] as something that you identify with.
[44:16] And I'm not sure if that's the thing or one of the things.
[44:19] But what do you think?
[44:20] Reflecting back on things that kind of were the protective factors
[44:25] for you that allowed you to, in some ways,
[44:28] probably still suffer and other ways, sublimate that into.
[44:31] Because you also mentioned earlier that anxiety has a purpose,
[44:34] which I totally agree with, right?
[44:36] It has a value.
[44:37] We wouldn't have it if it didn't have a value.
[44:39] It could be protective.
[44:39] Yeah. That being said, to your point,
[44:42] it hits the threshold where then it becomes unproductive,
[44:45] maybe a barrier to you.
[44:48] So, yeah, looking back,
[44:50] what are the things you think that, you know, beyond the adverse ones
[44:53] on the other side of that were things that helped you kind of
[44:57] steer the ship to where it went?
[45:01] Family, friends and faith, if I were to shorten it.
[45:03] I mean, I'm a faithful person, I'm Catholic.
[45:05] So there are times that I draw on that,
[45:07] drawing on a resource that's greater than myself is helpful.
[45:12] But really, I'll be honest, my mother,
[45:15] I read I lost my mother about a year and a half ago to pancreatic cancer.
[45:18] But she has been my rock.
[45:22] And my father, I lost brain cancer like 13 years ago.
[45:25] So both my parents are gone now.
[45:27] But having that family foundation to draw on my brothers,
[45:30] my sister, we're still tight after all these years.
[45:33] So having that as that safety net, that community,
[45:36] that close knit community and then a broader circle of friends.
[45:39] I'm fortunate to have great people in my life still do.
[45:42] So I think that there are times when I go it alone and I want to.
[45:47] I like going on retreats.
[45:49] I haven't done it for a few years since COVID,
[45:50] but I love getting away for a weekend and self-care and clearing my head.
[45:54] And so so I've used a lot of tools.
[45:56] But if I would summarize it, it's mainly family, faith and friends.
[46:00] So belonging, where does that fit in with that?
[46:03] Like a sense? That's really the essence of it.
[46:05] Community, the sense of community and connection with others
[46:08] and having that power beyond yourself that you can draw on,
[46:12] you know, among your family and friends in your community is huge.
[46:15] It's huge for kids and it's huge for us adults, right?
[46:19] And so that's an important part of resilience along with,
[46:22] you know, building the confidence and the competence that you can handle.
[46:25] And with that comes weathering challenges and struggles.
[46:29] And as a parent, this is where our job is tough.
[46:32] We don't want to see our kids in pain.
[46:34] We want to save them from pain.
[46:36] And we should.
[46:37] But there's a bit of that that's a learning
[46:39] and I'm not going to sound like let your kids suffer.
[46:41] I mean, I'm all for treating pain.
[46:42] I'm all for seeking help when you need it.
[46:44] But sometimes there's I think I've even seen a trend
[46:47] over the last 15 years to as little pain as possible.
[46:51] Oh, yeah, yeah.
[46:52] Where I mean, to the point where that's one of the reasons
[46:53] people don't vaccinate their kids is they don't want to poke them.
[46:56] And so and there's other reasons.
[46:58] But but so and I get that nobody.
[47:00] I mean, you're a masochist if you want it.
[47:01] Sure. But but physical pain
[47:04] has some benefits sometimes, you know, you got to go through a little
[47:07] to get where you got to be.
[47:08] And also the the challenges in life,
[47:10] whether they're emotional, psychological, social
[47:13] with that support structure, it helps you build the competence
[47:17] and the confidence that when life gets rough again, OK, it stinks.
[47:22] But I got this, right?
[47:24] And if I don't have this, I know who to reach out to for support.
[47:27] Yeah. And that's the essence, I think, of that resilience,
[47:29] building that family inner circle.
[47:32] And then beyond that second tier is
[47:35] but a lot of kids are lacking that I think of kids in foster care
[47:37] and kids that go through, you know what I mean?
[47:39] So that's why we the helpers are there to kind of help smooth the road.
[47:42] Yeah, I mean, it makes me think this has come up actually, believe it or not.
[47:46] I want to say a number of times in our short episodes,
[47:50] people have many yet on this podcast.
[47:52] But there's a book I'm sure you're aware of called
[47:55] How to Raise an Adult by Julie Lythcott-Haims.
[47:58] I've read it, but you heard about it.
[47:59] Yeah, so it hits on that.
[48:01] Her work at Stanford, she could see that the
[48:04] the progression of the, you know, general student
[48:08] that she would see at Stanford change over the years
[48:12] and in part due to this idea that we're going to take away the barriers.
[48:17] You know, to have my kid have an easier life.
[48:20] And at some point in life, life hits you.
[48:23] I don't care how smart you are.
[48:24] I don't care how, you know, how many resources you have or whatever.
[48:28] Like you will hit some limit.
[48:30] And she would see it happen at Stanford, because you're not
[48:33] you're not the valedictorian anymore.
[48:34] Get out of your bubble and stuff happens.
[48:36] Yeah, you know, so you're for the first time like I don't have an A plus
[48:39] or I'm not excelling in this way or I don't have the same support
[48:43] that I had or something like that.
[48:44] And it's she's seen it and she names it to be somewhat detrimental to youth.
[48:49] So it's not give those experiences of struggle.
[48:54] The scars in life, the challenges, I'll call them the scars in life
[48:58] can lead to immense growth.
[48:59] Yeah, but you need that resilience, that support system.
[49:03] And and sometimes it does knock you down for a while and you need help.
[49:06] Right, like people in like mental health care, for example.
[49:09] Yeah, well, and you hit on kind of I think I want to speak for you
[49:12] about the privilege of you having and belonging like for to have siblings,
[49:16] to have parents that live long lives.
[49:18] I'm sorry to hear that they're no longer with us.
[49:22] And how maybe when youth don't have that sense early on,
[49:27] maybe that's one of the biggest factors that we see in our practice
[49:31] of the difference between an adverse experience being something that
[49:36] can resilience can where it's had or or not.
[49:39] You know, I tell people like, you know, people that join gang sometimes aren't bad people.
[49:44] They're people that have nowhere else to feel belonging for community.
[49:47] Yeah. And the gang will give you that.
[49:50] Yeah. And that's where like engage, you know, we're pretty intentional
[49:54] actually about serving certain communities that maybe
[49:58] still don't feel like they can belong to the general society.
[50:02] Maybe that's their perception and maybe sometimes reality,
[50:05] you know, to give them a different experience when they're in our office
[50:09] of belonging and feel like they don't have to fit in.
[50:13] Because I think it is it.
[50:15] Brené Brown, I believe that talks about that difference
[50:18] of fitting in versus belonging, right?
[50:20] And how fitting in is like, I'm going to change myself to fit
[50:23] a square peg into a round hole and belonging being like who I am.
[50:27] I can just it's really about being loved for who you are.
[50:30] Right. If I'm going to really go deep, I'm going to say we're all looking for that,
[50:33] right? Hundred percent. And not in love.
[50:36] Nowadays, some people say, oh, I love chocolate.
[50:37] I love that song. This is a this is a deep love.
[50:40] It's it's a love where and I I try to bring that to my job.
[50:42] I don't talk about it.
[50:43] But I I love what I do.
[50:45] But I in a sense love the families that I work with.
[50:48] Yeah. And and I and I hope that that shows and I shows
[50:51] in how I care and that I listen.
[50:52] It does because it because talking isn't do it.
[50:55] Yeah, talking is that, you know, it's it's actions, right?
[50:58] And kids in particular teens can spot hypocrisy.
[51:01] Oh, yeah. Yeah.
[51:02] So if you're not they're good, if you're not authentic, they got you.
[51:05] Yes, I I love that.
[51:07] Me too. Yes.
[51:08] Not it's not always easy.
[51:10] There's there's a mirror that pops up pretty quick, you know,
[51:14] with less filter and a little more bite to it.
[51:18] Yeah, it's my it's my favorite.
[51:20] Is it pediatrician like you see?
[51:21] I mean, obviously like newborns through, I mean, I'm sure.
[51:24] Twenty three twenty two.
[51:26] I have the talk like this is the last year you got to move on.
[51:28] And it's tough. I now see babies whose parents.
[51:32] I was their pediatrician from birth.
[51:33] It's a real privilege that happened to me.
[51:35] I had my pediatrician who stills in practice
[51:38] and he was at my college graduation because his one of his daughters
[51:42] graduated the same college.
[51:44] So I saw him in some capacity and it was a trip to go back.
[51:48] And his office looks the same as it did in eighty five.
[51:52] It's it's a time.
[51:54] Stable. It's a stable.
[51:56] But again, but that's that was the that was the stability, right?
[52:00] In times of distress was that office and that person.
[52:03] And I just again want to thank you for being that for for so many people.
[52:09] I hope you carry that with you in a positive way.
[52:14] Thank you.
[52:15] You want me to tell the story that you want to cut it in
[52:17] about the first experience with dying patient or not?
[52:22] Is that too much?
[52:23] I mean, that way you can chop it, put it in if you want or not.
[52:26] I mean, I think that's a great.
[52:27] That's a up to you. It's up to you.
[52:29] OK, it's I don't we don't have a preference that this is about you and your story.
[52:33] I mean, I know. Yeah, absolutely.
[52:46] What more do I have left to do? OK.
[52:55] Sure. OK.
[52:57] So we've talked about, Chris, you know, kind of where you've been,
[53:02] where you're going and to kind of wrap up our talk today,
[53:05] which I hope we get to talk again.
[53:07] You know, where you've been, there was you had mentioned off camera
[53:12] a moment where you were taught or you got you ingested some
[53:21] some teaching of how you had to show up in the room as a doctor
[53:25] and what your role role was for difficult times
[53:29] and how you have shifted since then.
[53:32] But you had that one experience that you told us,
[53:35] could you share it with us about that patient?
[53:38] Yeah, when it comes to the human side of what I do and my
[53:42] with the experience as a pediatrician, I I still remember like it was,
[53:46] you know, a week ago, the first patient of mine that died.
[53:49] I was in my training at Children's Hospital Los Angeles,
[53:52] which, as I said earlier, amazing training.
[53:54] But you saw a lot of bad diseases and this child was barely two years old.
[53:59] And I was only on the job about a month.
[54:00] I was a brand spanking new pediatrician and I was on call
[54:04] the night that she passed and it it hit me hard.
[54:08] And I tried really hard not to cry in front of the family.
[54:11] And I showed some emotion, but then I went on the hallway
[54:13] and I cried for a very long time.
[54:15] So for a while, the way I dealt with that is I would go in my office
[54:18] and shed my tears and try to not show it, thinking that I needed to put on
[54:22] that stern professional objective face.
[54:27] Not that I was afraid to show emotion,
[54:28] but I just felt like it wouldn't help.
[54:31] You fought against it because your role you felt was to be that stoic.
[54:34] I stifled it and I showed it on my own time, which is when I'm in my office.
[54:38] And so or at the end of the day or whatever.
[54:40] But I I've been to funerals for kids.
[54:44] Those are the hardest funerals I go to, aside from my dear family.
[54:48] And they hit me to the core and it shows me that I'm really deep.
[54:51] I'm in a privileged space with families, but I also it taught me how to
[54:55] it's OK to be real with them and show your emotion.
[54:59] And you can do it without losing your professionalism and your objectivity.
[55:02] And in fact, it doesn't hold it back.
[55:04] I think families appreciate that you're real with them.
[55:07] And I think they then will learn to hopefully respect and trust you more.
[55:10] They do. I'm going to share a story of that's OK, too.
[55:14] But about my experience, I mentioned my mom going through many different doctors
[55:18] and all of them good doctors, capable people.
[55:24] There was a skin doctor in actually locally here in Westlake.
[55:30] I'm not sure if he's still practicing,
[55:32] but I remember my mom's course of cancer was it was spreading throughout her body
[55:37] and he caught one of the spreads in his work.
[55:43] But I remember in the office, it was one of those flash bulb memories,
[55:46] you know, those those memories that are very vivid to your point.
[55:49] Like it's like it was last week, you know, the other ones you don't.
[55:52] But this was important enough to me that it was that it was a split second.
[55:58] He went into the room and slammed down and said, damn it.
[56:03] Like he was impacted by this and it wasn't cold and it was actually angry.
[56:11] But I was angry and it in a weird way.
[56:16] It didn't feel uncontrolled.
[56:17] It didn't feel like he's a blowhard.
[56:19] It felt like he's a human and he's he gets it like this.
[56:24] This sucks. And that meant the world to me.
[56:28] So I I appreciate what you're saying that, you know, that you see that value.
[56:33] And the family do appreciate that.
[56:38] So transitioning, Dr.
[56:39] Tolcher, Chris, to to where you're going, you may mention early on that you're not done.
[56:45] Like you've done a lot.
[56:46] You've worked in hospital systems, you've worked in administrative duties
[56:50] and huge like conglomerates that are trying to change the world.
[56:55] You're started your own mom and pop.
[56:57] I don't know if you like that term.
[56:58] We use that term for us, but very small, you know, in the grand scheme of things
[57:03] where things are going, things are going bigger and bigger to serve more and more people.
[57:08] You know, we're we're kind of the local community people that that are trying
[57:12] to be human and doing it in an old school way, maybe or a different way.
[57:16] Or anyways, you may mention that you have you're not done.
[57:20] You have many more things to do.
[57:21] So can you speak to kind of your your hopes and wants for your career
[57:25] and where it's going?
[57:28] So yeah, I mentioned earlier that what I did with Dr.
[57:32] Stafford opening Parkway Pediatrics was has been a dream of mine for 20 years.
[57:35] And I did a few years ago, make a change.
[57:39] I was medical director for a company.
[57:41] I got to see this at a very high level.
[57:42] And there's a lot of change going on in health care, a lot of growing
[57:45] and conglomerating and buying out of practices and little ones becoming big
[57:49] and and multi basically multi site.
[57:54] And I'm not knocking out.
[57:55] There's I mean, there's great docs in all those.
[57:57] Yeah. And there's reasons.
[57:58] There are reasons and, you know, there's a lot of reasons.
[58:01] But I what I really wanted was to turn back the clock
[58:05] and offer a small, easy to access, parent friendly, you know,
[58:10] where, you know, everybody knows your name and people can access you
[58:14] and not and see you because they want to see you and not the one they have to see.
[58:18] And, you know, we visited your office early on.
[58:20] And I know how to I've built out offices and I know that like
[58:23] even the space we're in, it's like it's always, you know, the budget
[58:27] and it's a time, you know, it's like it's not done yet.
[58:30] Right. But I think one of the differences
[58:33] that I found in your office from just the get go was it was intentional.
[58:38] Like things were intentional and that's hard to replicate at scale.
[58:42] Does that make sense?
[58:43] Like in this other model that again, there are reasons that that
[58:46] maybe has to happen or is happening.
[58:48] It's a it's a needed attempt or response to other things, other pressures.
[58:54] You know, but your office.
[58:56] I remember even like you had this like you probably still do.
[58:58] I haven't been really recently, but like a screen that projects on to.
[59:02] And I'm like, that's freaking amazing game on the wall.
[59:05] Yeah, but it's like it's like it's interactive.
[59:08] It's like it's intentional.
[59:09] It's like, OK, they're in a waiting room.
[59:10] How do we make this more friendly?
[59:11] How do we I don't know the thought behind it, but I could imagine
[59:15] that that was thought of and de-stress what can be a stressful
[59:18] situation for a lot of young kids.
[59:19] There are a lot of kids aren't happy to see the doctor.
[59:22] Correct. So, yeah.
[59:23] It's now it's hard to get them up.
[59:24] What's that? It's scary.
[59:25] They get poked or prodded or what's he going to do?
[59:27] What's he going to find? Is it going to hurt?
[59:29] And so, yeah, it does help.
[59:30] It was one of the better things we did in our way.
[59:33] So, yeah, I guess I'll say one more comment on where I see myself
[59:37] going that I say I'm not done is that I yes, I'm trying to build
[59:42] a small family friendly yet up to date, easy to access practice
[59:47] and then turn it over to people that I trust and adore to manage it
[59:50] when I'm ready to retire, which is not soon.
[59:53] But anyway, I also
[59:57] I'm a helper at heart and I want to help as much as I can until I can't.
[60:01] And but I don't want to go so far like I told my wife and I told
[60:05] actually Dr. Stafford and my daughter, who also works with us
[60:07] as an retrospective, I said, if I ever get to the point
[60:10] where I'm a hindrance to the practice, then tell me
[60:13] like I don't want to be dragged out the door.
[60:16] I want to leave when it's time for me to leave.
[60:18] And I'm nowhere near that.
[60:19] I mean, like I said, I think I have at least 12 years
[60:21] in me before and maybe God willing, maybe more.
[60:23] But we'll say it's exciting.
[60:25] I love I wish I would have done this 20 years ago.
[60:28] It's rough. I'm not going to lie.
[60:29] Starting a new business is rough.
[60:30] You take a hit. It's stressful financially.
[60:33] It's rough. You're propping it up.
[60:34] And it's, you know, but we're moving in a great direction.
[60:36] And I think if we provide the previous experiences that I had,
[60:40] especially seeing pediatrics at a very high level
[60:42] when I was a briefly a regional medical director,
[60:45] I got to see what's going on in the field.
[60:47] And there's a lot of good stuff.
[60:48] There's good things they're doing.
[60:50] But I also got to see that the challenge there
[60:53] is keeping that everybody knows your name in the small,
[60:57] you know, privately run and great people where I've worked before.
[61:01] I've worked with great people everywhere and I'm not knocking anybody.
[61:04] But I had a vision for what I wanted.
[61:07] Yeah. And I'm glad that I'm finally making it come true.
[61:09] It hurts for a while, but I see myself going in a great direction.
[61:12] You're passionate about it. I am. It is my passion.
[61:15] I mean, I'm lucky to do what I do.
[61:17] It's a privilege space to be with people.
[61:19] I get to use my knowledge to help others,
[61:23] my diagnostic abilities, my humanity to help others and meet them where they are.
[61:27] And and honestly, I go to bed every night
[61:30] thankful for what I do.
[61:32] It's not always easy.
[61:33] I lose sleep over it, but I love what I do.
[61:34] I can relate to that and to know that there's light at the end of that tunnel.
[61:38] Nothing lasts forever.
[61:39] So there'll be ups and downs and that's part of the package, isn't it?
[61:44] That being said, I have a sense you're not retiring any time.
[61:47] So no, oh, no, you have too much to give.
[61:51] And I mean, you've heard of the Blue Zone stuff, right?
[61:54] Like, you know, people that are good at something
[61:56] and are passionate about it, that is needed.
[62:00] You can help longevity and wellness, right?
[62:01] You can do that until well into your hundreds.
[62:05] Here we go. We'll see.
[62:06] We'll see. All right.
[62:08] Thank you, Dr.
[62:08] Thank you. Appreciate it.
[62:10] What a fun conversation. Wow.