Transforming Patient Care
Kara Wada, MD: Welcome back everyone, and a big welcome to any of our new listeners. I am Dr. Kara Wada. This is the Becoming Immune Confident Podcast where we talk about all things, allergies, autoimmunity, anti-inflammatory living, and really building that resiliency that we need to live with conditions that have too much inflammation.
I love welcoming some of my esteemed colleagues to the podcast as guests, and today we have none other than Dr. Kara Pepper. So it's a meeting of the Dr. Karas. Dr. Pepper is a practicing primary care internist and a coach based out of Atlanta, Georgia. And after 14 years in private practice, Dr. Pepper built her own solo telemedicine practice for adults across the southeast, especially those who are struggling with eating disorders.
She coaches exhausted perfectionists through career change, burnout and impostorism. She provides one-on-one and group coaching, leads retreats, and speaks on topics surrounding clinical wellness. Thank you so much for taking time out of your busy schedule to talk with us today and to share some of the wisdom.
I've been just gathering along the way following you on social media, so I'm so glad to connect.
Kara Pepper, MD: I'm so glad to be here, especially to have a fellow Kara with a K.
Kara Wada, MD: We were talking behind the scenes that it's Kara because with the C it would be Cara. Cause it looks like a car, right?
Kara Pepper, MD: That's right.
Kara Wada, MD: So no, no offense to those who buck that trend out there as well.
Kara Pepper, MD: Yes.
Kara Wada, MD: So Dr. Kara, can you explain your story, like how did you end up in this really cool area of medicine and coaching that you practice in?
How Dr. Kara ended up with telemedicine practice
Kara Pepper, MD: Yes I will summarize it by saying I learned the hard way. And so that's ultimately how I ended up here.
Long before I was a physician, I was a professional ballet dancer. And for the record, dancers and doctors are really the same people. We're lifelong learners. We show up at work trying to get better and better at what we do every day. Lots of perfectionism and workaholism, my career as a professional ballet dancer was cut short because of injuries ultimately for my own disordered eating, which I did not have a name for.
And certainly it was encouraged at the time in that career. And so I just pivoted all those behaviors into a career in medicine and that took off. So all my perfectionism and workaholism came with me. I looked great on paper. I joined a practice of largely chief residents and I just epically crashed and burned with burnout about seven years into my practice. And the whole time I was looking around thinking there's something wrong with me. Everyone's got their act together. Everyone else is doing just fine, and I'm clearly the one who is failing here. So eternally was looking at ways to change my practice, change my circumstances, change my kind of career focus.
And I'd had this following that was growing of folks who had been struggling with eating disorder behavior. And I just told myself I was a really good doctor. Like I just understood them. I just was great at taking care of them. And really I was them. I just didn't have acknowledgement of that at the time.
So I'd built this following of eating disorder folks and meanwhile, in an effort to fix my burnout, built some telemedicine line of service in my brick and mortar practice, and then the pandemic happened. And I think for many of us it just shifted and helped clarify what was really important. And so despite the fear and anxiety of the pandemic, I was living my best life doing telemedicine from home.
And I was like, why am I not doing this full-time? So that started this whole process of saying, I deserve to be happy in this life that I work so hard for. I wanna be able to deliver amazing care to my patients doing things that I love. And so I stepped off this very traditional model of healthcare and started my own telemedicine practice, which I still do primary care, but I really do focus on eating disorder behavior, which is everywhere in our diet-heavy culture.
So here I am.
What is diet culture?
Kara Wada, MD: Maybe we can dig into that and talk a little bit about. What exactly is diet culture? I don't think we've talked about that on the podcast.
Kara Pepper, MD: Yes, if you don't mind me just diving deep into the pool, straight up.
Kara Wada, MD: Absolutely.
Kara Pepper, MD: Diet culture really originates from several hundred years ago.
It's really rooted in white supremacy and anti-blackness because if you think about all those Renaissance paintings that you see of these full figured kings and queens, fatness was revered. It was a sign of health and wealth. And as colonization started to take over it, this dichotomy of body sizes about what is a good body and a bad body became part of this racial power struggle.
And all of a sudden the thin white European body became the ideal as opposed to this curvaceous more muscular style body. And so there's a lot to be said about the history of the BMI, which I've talked about extensively. But ultimately, when you fast forward into current society, by the time kids are five, they recognize that thin is worthy and fat is not.
And so we have at least half of kids in elementary school already starting to diet 90% by the time people are in high school. And not surprisingly, having a fat body is one more sign of being marginalized in America because of this thin privilege and thin expectation. And so diet culture, I think was handed to us very explicitly from our parents' generation, our grandparents' generation and beyond, to say, "This is what it should look like".
And it's been associated with morality, with control, with privilege. And so it's not surprising that the medical establishment itself is so anti-fat bias. And so we all, myself included, we're taught that if you wanna be healthy, you need to be thin. And so I could talk for probably hours about just this one topic, but suffice it to say I'm actively undoing a lot of the advice I gave to patients early in my career 'cause bodies were designed to look in all different shapes and sizes. And so patients get to decide what health means to them as individuals and so it has this element of gaslighting when patients are like, I just wanna be well, I don't wanna be told what my body needs to look like. So that's the short summary.
Kara Wada, MD: I think it's so enlightening and I, too have seen many of the things that I say to patients change and evolve. Maybe not as fast as I would like to see them. In some of our practices, admittedly within an allergy immunology clinic, weight doesn't come up as often in the discussion.
Although we know that there is some factoring into asthma control in certain particular conditions. But as the pendulum kind of swings, I am just, I'm thinking about my own practice right now. Like sometimes when those conversations are uncomfortable, we do have this sense either lean away in an effort to try not to say something that might be harmful.
Undoing Harm and Providing Compassionate Care
Kara Pepper, MD: Yeah, absolutely. And I think that's really where we are. I think no matter how you engage in the healthcare system, whether you're a clinical physician, nurse practitioner, pharmacist, et cetera, or your patient engaging in healthcare or both, I'm both patient and a physician, it is clear that our healthcare system is fundamentally broken, and it is designed to make money for insurance companies and for hospital systems. And patients are having trouble accessing. They're having trouble finding someone who looks like them, understands them and is represented in a way that is meaningful to them. And then we are actively trying to undo a lot of the harm that we have been taught and we continue to perpetuate.
And when people are epically burned out and trying to hold the broken pieces of our healthcare system together, it's really hard to slow down and question, "Am I saying what's true? Am I being as compassionate as I could be? Am I giving the best, most updated medical advice?" 'Cause we're just trying to get through our day.
And so I love that you just say that we're just trying to undo some of the harm that we've created because we love taking care of patients. We wanna take great care of them.
Kara Wada, MD: Yeah, I see it coming up in my parenting too, talking about this passing on through the generations.
Thinking back to some of the lessons my sister and I learned from my mom, she was doing the best that she knew at the time, seeing her with her Rice cakes and non-fat yogurt. And salad express with the non-fat dressing, all of that calorie counting craze is what I grew up amongst. And in trying to reconcile that as my oldest is now in that range where she's mentioning or asking about calories when she comes home from first grade and oh yes, I think the conversations are just gonna continue.
Kara Pepper, MD: Yes, there's an excellent book that was just published last month called Fat Talk.
It's written about fat bias, particularly not only in healthcare and in culture, but how can we not pass on this tradition of harm through diet culture to our kids? And I'm happy to give you that information for your show notes if you like, but it's such a way for people to reclaim language and to really protect their kids and teach them.
To love their body and to use their voice in a way that's really meaningful. That's such a great one.
Kara Wada, MD: Oh, thank you. I have to say, one of the positive things for me to come out of the mess of the pandemic is I rediscovered my love of reading and incorporating that into my daily routine and practice.
So I will add that to my Kindle list.
Kara Pepper, MD: Yeah, it's definitely worth a read.
Embracing Inclusivity and Compassion in Patient Care
Kara Wada, MD: So what are some things that I could do in my office to help be more aware or to be more kind and compassionate as I'm thinking about my patients who may have some issues with disordered eating or related things going on.
Kara Pepper, MD: Yeah, so I think it starts well before patients ever set foot in our office from how they're onboarded. Are we showing that we are inclusive? Are you asking about pronouns? Are you asking about are you requiring weight and insurance information first thing before you even have the patient walk in the door?
There's ways that we can signal, we wanna take care of everyone. In the exam room, do we have chairs that fit all different sizes and shapes of bodies? Is it necessary to weigh your patient? I would say in the adult world, I'm an internist. There are very few reasons that we actually need to weigh someone maybe trending weights for a very specific reason, or perhaps some medications that may need to be weight-based, anesthetics for example, and then in pregnancy.
But generally speaking, like if a patient's coming to me for a general medical issue, if they're coming for a cough or cold, I don't need to weigh them, and I certainly don't need to bring that up unless it's a relevant concern to the patient. And so there's ways to signal psychological safety by showing inclusivity and showing that we actually want all sizes and shapes of bodies.
And then, instead of assuming that the patient wants to be thin, although patients are certainly indoctrinated with diet culture, I just tell them upfront, this is a piece of data, it is not the piece of data and you get to determine what health looks like to you. So let's talk about that. And very often, for example, I have a patient say, "I just, I wanna be healthy."
I'm like, "What does that mean?"
" I think I should lose weight".
"Okay. What does that mean? Why is that important to you?"
" I wanna be able to chase after my grandkids."
"Okay. What's keeping you from doing that?"
"Okay, my knee pain is really bothering me".
I'm like, "Okay, so let's talk about knee pain. Let's talk about all the ways that you can do that. And so one of the questions I have for my physician colleagues, and also I tell patients to ask is, "If you could not talk about weight, what advice would you give me?" It's the same way as if someone came in and they had kidney failure and they couldn't take certain medications, we wouldn't be like I just think you should take them anyway.
No. We'd be like, let me look at all the different ways that we can manage this. And so our medical problems are no different. We should be able to say, what is the way that I can look at you as a human and say, what are all the ways that we can manage this, even if weight's not on there? And then lastly, there are formal, screening questionnaires for eating disorder behavior.
But the first one that I start with patients is like, what is your current relationship with your body food and exercise? And that is a very helpful question because it really gives you more information than some of those screening questions will. So that's where I would start.
Kara Wada, MD: Can you imagine, that gives you more information than just about, those questions alone are huge.
Kara Pepper, MD: Yeah, absolutely.
Kara Wada, MD: If we take the time to ask them and to listen for the answers too.
Building Trust and Easing Suffering: Transforming Patient Care
Kara Pepper, MD: Yes. And I have a lot of empathy as someone who's personally struggled with burnout and I coached other colleagues through burnout. The thought that comes up for so many of us is like, I've got 10 minutes to see this patient and they wanna address five different issues.
I don't have time. It's the same amount of time. If a patient can't be honest with you, it's gonna take more time to get to the root issue. So just start from a place of openness and the efficiency in your visit will actually get better 'cause patients will trust you with the real information that's there and we have to earn that trust back.
Our healthcare system has done a lot of harm and so patients deserve to have the time and space they need to tell if we are trustworthy and these are some ways that we can get started with that.
Kara Wada, MD: I think that is so important that I'm gonna reiterate it like that trust is not an expectation and assumed. And I think that is something that is missed far too often.
Kara Pepper, MD: Yes. Yeah, exactly. It's scary, right? I think we all know that. Like if my mom was admitted to the hospital for example, like I would make sure I was there or my dad was there because patients need an advocate. And I do believe that our colleagues truly feel like they're doing the best that we can.
But we can also do better. We are lifelong learners, like I mentioned in the beginning. So this is one way we can start looking at our practice and saying, "How can I ease suffering? How can I build trust? How can I look at some of the things I've assumed?" Of course my patients trust me, but those are the people who are seeing you. What about the ones who are not quite sure if they can? So how can we re-look at our systems and our way of practicing to make it more trustful.
Kara Wada, MD: Comes to that idea of being not only trauma informed, but mitigating trauma along the way.
Kara Pepper, MD: Yeah. And naming it. I start with every new patient saying, "I assume by the time you're seeing me that you've experienced a lot of healthcare trauma. So this first visit is really a chance for you to get to know me and see if this is the right fit".
I don't assume that they're gonna trust me. I have to name it from the beginning.
Navigating Burnout: Generational Perspectives in Medicine
Kara Wada, MD: Yeah. I'm just sitting with that for a second. Yeah, it's huge.
Yeah. And as we think about that role of burnout, I always come back to that simple saying of hurt people, hurt people. And I think that's the other space that we really have kind of some overlap in this idea that we need to help our colleagues in order to help our patients as well.
Kara Pepper, MD: Yes, absolutely. It's one of the reasons I love coaching so much. It feels like the true deep healing that I came into medicine for to help my patients. And it really does allow people, our colleagues, again, in a place of trust because we have this commonality, same language, and same lived experiences to start to unpack some of the trauma that they've had in their own training and continue to have with moral injury and trying to deliver care in a system that continues to create harm, not just for patients, but for us, the people who are practicing in it. But there is hope, right? Because there's this generational divide. I think it. Everywhere, but particularly in medicine, right?
There's the Gen Xers like me who were latchkey kids and you just suck it up and do the work, right?
Kara Wada, MD: Yeah.
Kara Pepper, MD: And we have these quote millennials who are coming in and they're like, they've watched us burn out, they've watched us get divorced, they've watched us go through all of this. And they're like, "I don't want that life, like who would want that? So I'm gonna set some really firm boundaries on what I'm willing to do. I'm gonna do my job, do it well, and I'm gonna go home". And so all the mid-career folks like me are like, "What's wrong with these new people? They don't wanna pick up all this unpaid work. They don't wanna volunteer after hours. Like I guess I'll just have to keep doing it". And I'm like, "You need a mentor who's under the age of 35, 'cause they really do understand how to build sustainable careers". And that resentment that you're feeling is really a testament to how burned out you are, overworked you are, and how much the system needs to change.
So anyway, I have a lot of hope for the future of medicine because we've got this generation of docs coming in saying we wanna do it better, so we need to listen to them.
Kara Wada, MD: Yeah. And I'm an elder millennial, so I feel like I'm in that bridge between the two. And feel very fortunate that my burnout happened actually very early in my career.
It was like two years into my attending role. And that's when both my health and everything not really blew up, but just bottomed out, I guess is a better way of putting it. And and it is so true. We've had discussions within, I am associate program director for our fellowship, just in the evolving needs and attitudes and things with the fellows we've had in the last few years and it really does help my colleagues that are in the Gen Xers recalibrate and I think the pandemic in some ways, despite all of the heartache and loss and all the badness, I think, it also did create a time for the recalibration of, "Okay, what really needs to be in person, what can be done through telemedicine or through Zoom meetings". And we had the pendulum swing from one side to everything virtual. And now, just this last week, we were meeting to figure out, "okay, what is this new middle ground where we're fostering wellness and education for our trainees as well". Trying to counteract some of the... allergy immunology fellowship is probably one of the least malignant cause of medicine as one would think.
It's like pretty eight to five ish and call, generally you're not going into the hospital and yet it still is an intensive job and you are absorbing trauma from other humans that you're interacting with.
The Heart of Rest and Recovery in Medicine
Kara Pepper, MD: And that's right. Yeah. I liken the analogy to the heart, right? We have systole where the heart squeezes and diastole where the heart relaxes, and every time, there's effort. There's an immediate recovery process that happens afterwards. We're not like, "Stupid heart. Why do you have to rest and recover every time you feed?" We're just like, "That's just how it is. It's the cycle that it goes through".
And then the analogy of the coronaries, which is the first branch off the aorta, it goes back and feeds the heart, right? So literally, the thing that continues to keep us alive is perfectly designed to restore itself and feed itself before it does the work of caring for the rest of your body.
And that analogy in terms of the system of medicine and often the way that we live is just like working until we crash, working until we've done it, done enough, which means we're brain dead, exhausted, depleted, et cetera. And frankly, we don't get paid to rest. We don't get paid to recover. There's no RVU compensation for that.
And so it's highly undervalued, but it's rest and recovery is where our creativity, our intuition, our problem solving, all the solutions that we're looking for, lie and wait for us and rest. And so it really is not optional, it is how we actually deliver amazing care and continue to have sustainable careers.
So this past year for me, as I've left my previous practice and started this eating disorder practice, has been highly focused around rest and recovery, which is such an interesting way to practice medicine. I'd never seen it modeled before, but I was like, this is what I need. So it's been amazing.
Kara Wada, MD: So how does that look? I'm curious.
Dr. Kara Pepper's Work-Life Balance
Kara Pepper, MD: Yeah, great question. So part of it is to allow myself an internal expectation that I don't have to be perfect all the time, and that the system that was laid out for me is not necessarily the one that works for me. So to just wipe the slate clean and design something is part of that.
I take a Lunch Break. It's this like novel concept called not working through lunch from your desk. Yeah, I know. It's really amazing. So I intentionally block time where I rest in the middle of the day. And because I am the boss of me and have stepped off the insurance realm, I'm able to value my time in a way that is really important.
And so I'll be candid, some of the pushback about that is, oh, you don't take insurance. But as a patient, I'm spending a fortune through insurance. And so I felt very confident in saying I can provide exceptional value and time that patients deserve for the same cost. So in any case, it looks like valuing my time in a different way.
And there's a lot, I don't know how many of your listeners work in healthcare, but there's a lot of conversation about what is the appropriate panel size for primary care physicians. And that number is generally around 2000 or 2,500 patients. I had well over 3000 patients I was taking care of in my previous practice, and now I have about 120, which is such a huge difference.
But when I have 120, I'm just more efficient, I'm more engaged, I'm able to provide better care. It's pretty amazing and what I have found is that I am so much more impactful in that way because my brain has space to recover from all the work I'm doing every day. So , it's a little bit what it looks like.
Kara Wada, MD: That's amazing. I recently came across in, I'm not super well versed on it, but this idea concept of Dunbar's number, this like number of human to human relationships that we are actually able to maintain. And I wonder how that factors in. It was a crossword clue recently, so I need to dig into this a little bit.
Kara Pepper, MD: Yeah. I'm really interested.
Kara Wada, MD: I would be curious to see what that is and how that relates. Because really there is, to some degree, a limit to how much we can remember and keep in our working memory and be able to be engaged. I've realized and I'm still within the academic world, but I have realized that I function so much better working about two and a half days a week clinically.
And when I have those patients who are the more medically complex or socially complex the second, third, ninth opinion. I've been incredibly fortunate to be able to maintain longer appointment times, and I've realized that I'm only able to really, genuinely, and fully show up for a certain number of those patients in a period of time before I need to refuel because when you hear those stories of medical trauma or the pain that other folks have gone through, it has its own impact.
Kara Pepper, MD: Yes, absolutely. There's real emotional labor to that. Whether we're delivering a really tough diagnosis, you've got cancer, you've got something life ending, life limiting or you have patients who are just like, "I'm so frustrated. I'm so angry that I feel like I've been abused and abandoned by our healthcare system" and they're sharing that with you. There is emotional labor in that, and we're expected to just move to the next room and act as if nothing happened and apologize for running late, when in reality these are real humans that we're dealing with. And so when I talked about the hope earlier, that really is the hope that I have is that this new generation of folks and people who are reinventing the way we're delivering healthcare is how can we center the patient again and what really matters, patients deserve it and so do we. It's the reason we keep showing up 'cause we really love this work we do, even though sometimes we're distracted by the administrative stuff that is required unfortunately.
Kara Wada, MD: As I was just thinking, I was like, how can I reclaim my lunch from my inbox?
Kara Pepper, MD: Yes. Yeah, it's really interesting. If we look at athletes as a model for this, let's say they're a distance runner. They don't just get up and run long distances for eight hours a day. They run and they run short distances and then they weight train, and then maybe they get massaged. They do all these variable different things. And so the grind culture of medicine, of just churning through as many patients as possible, I think is analogous to that.
And so part of my rest and my own practice is, I have a couple different ways that I actually deliver care. I have my own practice. I subcontract with other practices that give me a kind of a different feel of medicine, more urgent care kind of stuff. I coach, I speak, I have my own podcast.
I do all these different things, and it's still a way of delivering healing. It just uses different parts of my brain. So the fatigue is significantly less compared to how it was when I was just churning through eight hours of patients a day.
Kara Wada, MD: Yeah, because we are not an assembly line.
Kara Pepper, MD: We are not robots.
Kara Wada, MD: No. Robots with empathy chips.
Kara Pepper, MD: Yeah,
Kara Wada, MD: New AI.
Kara Pepper, MD: It's such a good way of looking at it. Like I'm picturing the big bad business CEO, just being like, "Here's your empathy chip. Say the right thing and hand the patient a Kleenex. Sit down and look at them at eye level. Just keep charting away the whole time.
Kara Wada, MD: There was something that came out recently about that, and I don't have it pulled up, but patients looking at something I think it was written by AI versus delivered by a human and AI one, if I recall. I'll have to pull that up too.
Kara Pepper, MD: That's so funny.
Healing as a community
Kara Wada, MD: Yeah. Interesting world we're evolving into, and I think it'll be fascinating. So I don't have any family members prior to this generation that have been in the medical field, but my husband's grandma was a practicing primary care doc for many years. Starting back in like the late forties, early fifties. And I imagine and think about the changes that she saw, not only within, certainly healthcare and advances and science and but also in the care delivery model.
And I've actually talked to my father-in-law about that 'cause he remembers going to the office with his mom as a young kiddo. And that she would spend time she would hold patient's hands, these things that we've really lost along the way. But I will be curious to see where things are towards the end of our career and how some of these technologies change, how our care delivery change. I think it'll be very fascinating.
Kara Pepper, MD: Yes. The thing that will not change is that we're all still human, and I think there's a real pull to have that connection. You mentioned earlier, going from Zoom meetings to now figuring out how you're gonna deliver residency fellowship education. I think it's the same way, like people, we are designed to be connected.
We're designed to be in community, and so that's the very human part of us that will, I think, win out in the end is how do we. Maintain that connection between doctors and patients, 'cause both parties deeply desire that and we know that is healing.
Kara Wada, MD: Yes. And help mitigate and heal trauma.
Kara Pepper, MD: Yes, absolutely. Absolutely.
Kara Wada, MD: I still wanna figure out how to get better eye contact through Zoom.
Kara Pepper, MD: Yes. I've tried a variety of different things, but I think the vertical screen with the webcam right above it.
Kara Wada, MD: Probably off a little center..
If folks were wanting to connect with you, they are maybe looking for a primary care doc or for our listeners who may be interested in coaching. How can they connect with you? How could they work with you?
Kara Pepper, MD: Yeah, so if you can remember my name, you can find me. So I'm Kara with a K, obviously Kara Pepper, MD and that's my website, karapeppermd.com. You can find me on every social media, Kara Pepper, MD. And always feel free to reach out. I talk a lot about eating disorder care, of course, but also just general wellness because I think all of us who are caught up in the grind culture in America are looking for some relief. And so I talk as if I'm speaking to healthcare providers, all of us are struggling with the same thing, all my female friends, et cetera. So in any case, I'd love to hear from you and just gimme a follow 'cause again, we heal in community. This is the way that we feel connected, even if we're across the United States.
Kara Wada, MD: Absolutely. Or even the world. We have some international listeners too.
Kara Pepper, MD: Sweet.
Kara Wada, MD: Thank you so much.
Kara Pepper, MD: Yeah, thank you for having me. This has been a really beautiful conversation and it's the thing that feels really healing to me too.
I think there's so much loneliness and to be able to talk about these things that swim inside my head all day long, it's really nice to be able to actually say them out loud and share them with your listeners. Thank you.
Kara Wada, MD: I totally agree. I was talking a little follow up with another colleague guest yesterday just about these conversations are really, what do give me hope for the future of medicine?
When we see and meet individuals who really are on their own road to recovery in different ways, whether it be burnout or health issues, what have you, and feels their why is so strong as to the work that they're doing and they're called to do.
Kara Pepper, MD: Yes. Thank you for having me. Thank you for having this podcast for your listeners, 'cause I have no doubt that people are seeing themselves in these stories.
Kara Wada, MD: Thank you so much and we'll again soon.
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