Joey Wahler (Host): They're often avoided. So, we're discussing questions patients are afraid to ask, but should. Our guest is Dr. Vickie Cox, a primary care physician. This is A Podcast A Day with Memorial Health System. Thanks so much for joining us. I'm Joey Wahler. Hi there, Dr. Cox. Welcome.

Vickie Cox, DO: Hi. Thank you for having me.

Host: Great to have you board. Appreciate the time. So first, why is it that many patients feel uncomfortable asking certain questions during a doctor's visit?

Vickie Cox, DO: Good question. I think there are a lot of reasons, embarrassment, fear of judgment. I practice in West Virginia where Appalachia culture runs rampant and mistrust of others, education, and just being able to really verbalize what's going on and the fear that comes with that.

Host: And so, as you point out, sometimes it's a cultural thing, right?

Vickie Cox, DO: Exactly. Really independent in the area in which I'm born and raised here in West Virginia. And we like to just figure things out on our own. Oftentimes, asking for help can be viewed as being weak when actually it's quite the opposite.

Host: Understood. So that being said, what role would you say trust plays between a patient and let's say their primary care provider or PCP, and how does building that long-term relationship benefit a patient's health over time? Because it really can come in handy if you've built that, right?

Vickie Cox, DO: Trust is critical, in my opinion. It's a vital role, just as important as vital signs in the office. We check blood pressure, heart rate, we look at your medications, but you have to be able to trust your primary care provider. You have to know that they have your best interest in mind. And that they are there to do nothing but help you.

Host: As I am sure you know, Doc, there's that old saying that if there are three people in life you should trust, it's your accountant, your lawyer, and your doctor. So, speaking of that, some patients hesitate to ask about symptoms they think may be embarrassing. So, why is it so important to bring up those concerns and be honest with your physician?

Vickie Cox, DO: It is very important to ask any questions or concerns you have. Peace of mind with your healthcare is vital. And understanding that your concerns are my concerns and my job is to work with you to help alleviate those concerns. Simple things that people may think aren't important. Not to be too graphic, but body odors changes in daily functions, things like that, that you're like, "Ah, no big deal." They can be critically and vitally important in finding new diseases and part of your healthcare.

Host: Absolutely. And along those lines, doctor, patients of course sometimes avoid asking for instance. Is this normal? Whatever it is that they're trying to convey, they're experiencing when it comes to changes in their body. So, why is that actually an important question? I would imagine a big part has to do with the fact that once you find out that you're not alone in a certain issue, right away, a lot of that discomfort goes away, yes?

Vickie Cox, DO: Yeah. And what's normal for certain people changes with age. Being a family physician, we treat from the time you're born to the time you're no longer part of this world. Hormonal changes, for example, in men and women, they can cause all kinds of fatigue, tiredness, bowel changes, headaches, vision changes, et cetera.

Those things change as we age. For example, I'm not going to expect a 60-year-old patient to do what a 20-year-old patient can do and feel good about it. Osteoarthritis is another great example of a disease process that changes over age. So, it's really important to verbalize that and for patients to understand that, over the long-term, how these things may progress and how they may affect you as a patient as they do progress.

Host: And of course, all of what we're discussing here is true when it comes to mainstream healthcare, if you will. But when it comes to weight, mental health, general lifestyle habits or substance abuse, many are nervous to ask questions about those things. So, how can a primary care doctor like yourself create a safe space, so to speak, for those conversations?

Vickie Cox, DO: That is very important that the primary care doctor and the patient have that relationship, that trust relationship. Again, practicing In West Virginia, in Appalachia, we have lots of mental health disorders, substance abuse disorders. This has to be a nonjudgmental zone. This has to be a safe space where you can tell me anything, and I can empathetically understand and help you through that process. Without being full disclosure and honest, it's hard to treat many disease processes that occur.

Host: How about the benefits to the patient of going to the same primary care doctor regularly and confiding in them on a regular basis? I would imagine one thing it certainly helps with from your standpoint is making a diagnosis and also a referral if that comes into play, right?

Vickie Cox, DO: Most definitely. It's hard to see a patient one time and figure everything out. And that may mean multiple doctor's visits. The thing that's really great about having a primary care physician is you build that trust, that relationship. You also can understand when you are in family practice, we see multiple family members, so disease processes that may affect one, It gives us a heads up or a predilection to help diagnose that in other family members. If your mother was a diabetic and you come in with those symptoms, that's already a key in our mind that, "Hey, we need to look. Check this." So, again, it goes back to trust, to feeling comfortable and to just having that follow-up with your primary.

Host: So, we touched on at the top of our conversation the fact that there are questions that doctors wish patients would ask more often, but don't, which is the first one that comes to mind when I mention that.

Vickie Cox, DO: What is it that I can do to help with my healthcare? When I leave and I walk out of this office and I get into my car, what can I do to help make me better for the next time I'm here? Whether it's diet, whether it's working on, hopefully, to stop smoking, but decreasing overall smoking, sleep patterns, sleep habits, lots of things that can be done. But that engagement of what do you need me to do, Doc? What do you need me to do the next time before I come in here?

Host: How about, Doctor, from your experience, if you're with a patient, let's say, first time or early on in the relationship and you can sense that clearly they're not being completely forthcoming with you. And if they were to be, it would be a lot more beneficial to them. How do you handle that?

Vickie Cox, DO: Again, this is a huge relationship. I completely understand that hesitancy with shame, judgment, guilt, remorse. "I don't know you that well. I don't want to tell you my deepest, darkest secrets which may be causing part of the issues of why I am complaining to you about what I'm complaining to you about." After doing this for a really long time, it's pretty easy to spot those. Every once in a while, I'll get patients that will surprise me, but calling them out on it, not the way to go for me. But developing that relationship, just like you would with any other provider is important.

Host: Yeah. I was going to ask you about the fact that This is really an example, building that trust and maybe dealing with someone that's uneasy at first. Really an example of where experience and intuition come into play, right? Things that they don't necessarily teach you in a medical school textbook, right?

Vickie Cox, DO: Yeah, a hundred percent. Eye contact, not being able to make it, diversions. It's pretty easy to see through that after having done this for two and a half decades. It's why they call medicine an art, in my opinion, not a science. It really comes with lots of patients and practice and in experience with these patients.

Host: Absolutely. Very well put. Couple of other things for you. Do you find in your experience with patients, Doc, that once the door opens and they are more forthcoming and they see that they can trust you, does that lead to more of that? For instance, if they tell you they've got body odor, might they then be more comfortable down the road telling you about a sexual issue they may be having?

Vickie Cox, DO: Yeah, a hundred percent. Again, it's that just kind of put your toe in the water and test and see what the temperature is. And a lot of times when they finally get to that point with you and that relationship, that they can trust you fully. They dive in and you get all kinds of things, and sometimes that involves long lists of complaints, which may mean multiple appointments or follow-ups in a short time period. I've had patients come in after we've established that kind of rapport with two pages' worth of lists of complaints. And we just kind of say, you know, "Why don't you pick the two most important ones today. And we'll address those and then we'll get you back here next month. And let's pick two more, and let's just work together to go through this."

Host: That's great. I'm sure that makes people feel a heck of a lot more at ease. In summary here, Doc, how can patients start with building a stronger, more trusting relationship with their PCP today? If they want to do just one thing to take a step toward that, what would it be?

Vickie Cox, DO: I think for me, it's just being able to talk to that patient and talk to that provider. It's a relationship between the two. That's not always a good relationship. It's not always one that clicks. That's not a fault of the physician. It's not a fault of the patient. You have to feel comfortable. Once you get that comfort level to where you can talk about that, sometimes—and patients laugh all the time, because I tell them sometimes you just got to literally, but not figuratively, grab your doc by the ears and tell them to sit down. "Look at me, look at me in the eyes, and let's talk about this."

As a physician, I can tell you it's EMRs and time limits, and this, that and the other. The patient is all that matters. And having that understanding that the patient feels like they're important. And that that time that you're in there is about nothing other than them is vital.

Host: Yeah, it seems like what you're saying there is simply that on the part of both you, the doctor, and the patient that you're treating, you both need to some degree to block out all the other stuff that kind of circles around a doctor's visit, insurance, copays, other patients in the waiting room, and just focus on the moment and making sure that you're both on the same page, yes?

Vickie Cox, DO: Exactly.

Host: Well, folks, we trust you're now more familiar with questions patients are afraid to ask, but should. Dr. Cox, you sound like someone people can trust. Keep up all your great work and thanks so much again.

Vickie Cox, DO: Thank you very much, Joey. I appreciate the time.

Host: Same here. And for more information, please do visit mhsystem.org/services/primary-care. Also, please be sure to subscribe for more conversations from Memorial Health System. If you found this podcast helpful, please do share it on your social media. I'm Joey Wahler, and thanks so much again for being part of A Podcast A Day with Memorial Health System.