Acceptance

When I was in high school, I had a friend who I always had a great time hanging out with.  He was one of those guys that always was upbeat and had a great attitude.  He never said anything negative about anyone.  He lived in the moment and that made him fun to be with.  The problem was that he was not always reliable.  We would make plans on a Thursday or Friday for the weekend.  I would show up to the planned event (movie, party, football game, restaurant) and about 50% of the time he would never show up.  This was pre-cell phone era so contacting him was not easy.  Sometimes I would find a pay phone and call his house and his Mom or Dad would say they were having family dinner.  Sometimes, the phone would ring with no response.  You might be reading this and thinking, “Get the hint, Weizer,” and the thought definitely would cross my mind but on Monday he would apologize and have a legitimate excuse for why he was not able to make it.  The problem was that I was not free and easy.  Growing up, I liked plans and I held myself and those around me to a high bar.  If I said I was going to do something, I was going to do it.  As such, my view of the world was very black and white; either you were reliable or unreliable and I wanted nothing to do with flaky people.  My friend was somewhat of an exception until he put me in a bad spot. 

We had arranged a double date.  I was very ambitious and picked a really nice restaurant.  My friend and I agreed to pay the bill adhering to our late 1980s male stereotype.  I showed up with my date about 15 minutes before the reservation and his date showed up around the same time but my friend was late.  We waited and about 15 minutes after our reservation, the hostess asked me if we wanted to cancel the reservation.  I was embarrassed and offered to treat our two dates to dinner myself.  We had a great time but when the bill came I realized I had enough to pay the check but not enough to leave a tip adding to my embarrassment.  To save face, I went to the waitress and explained the situation and she accepted my willingness to come back the next day to give her the tip (which I did do but I had to borrow money from my parents until my next paycheck).  On Monday at school, I went up to my friend and asked him what happened (this is the PG version).  He gave me an explanation and I told him that we were done hanging out.  He would try to talk to me after in the hall and called me at home but I ignored him after that and we did not talk our entire senior year. 

In between my junior and senior year of college, I was home and out having a few beers at a bar with some of my high school friends when “he” walked in.  We both spotted each other and feigned ignorance.  But his friends were my friends and my friends were his friends and eventually everyone was sitting around a pool table reminiscing about our tortured high school years.  Eventually he walked over to me.  We exchanged small talk for a little while and then, out of the blue, he apologized. But by then, I had become less rigid.  I learned that my plans did not dictate the rotation of the globe and I also apologized and bought him another beer.  We all had a great time that night sharing what we had been up to these last several years and bringing up funny stories about the past. 

What I had learned from high school to college was to accept people for who they are, not for what you want them or expect them to be.  This lesson has served me well in life.  At home, my wife and I both appreciate our strengths and weaknesses.  She pays the bills and manages the finances.  When I am not at work, I take care of all the immediate tasks- grocery shopping, taking out the trash, picking up and dropping off kids.  If it is a task, I am your man.  If you want long range planning in your personal life, go to my wife.  At work though, I am different.  I like strategy and planning but as a surgeon and physician have come to realize that plans need to be fluid.  But to be able to do this, you need to know who you are working with and acknowledge what they can contribute and not expect them to do something that they are not capable of.  When it comes to patient care, there are two really good examples of this.  Because I am a cancer surgeon, I take care of a lot of people who still smoke.  Some surgeons will refuse to operate on people until they quit smoking but I and my patients know that we sometimes do not have the luxury of time.  So instead, I ask patients what they are capable of.  I don’t judge them for smoking but I explain that the less they smoke, the better chance they have of success.  Sometimes patients refuse to change but they know that they are taking on more risk.  And sometimes they reduce or quit altogether (and we offer help).  Similarly, for patients who are morbidly obese, I do not ask them to lose weight.  Instead, we talk about what lifestyle changes they are willing to make to be healthier.  If they lose weight, that is great but even if they don’t lose a pound but feel better and are more active, then I feel like I have shown them a path for their future.  I lose nothing by meeting people where they are instead of demanding where they must be and, in return, I nudge people in a positive direction. 

In my leadership role, I try to do something similar.  Even though I became more nuanced in college, I still had a long way to go (and probably still do).  My first leadership role was one of my most challenging because I was surrounded by people who would neither say what they mean or mean what they say.  I spent a year trying to read in between the lines when I was having conversations with various stakeholders.  But I became good at observing not what people said but how they acted and reacted to circumstances.  That gave me the chance to appreciate what drove certain people to act and behave as they did.  Because I took time to understand what motivated certain people, it allowed me to interact with them more productively.  For some people, I had to find the win-win.  For others especially on my team, I had to learn to play to their strengths and leverage what they brought to the team avoiding their Achilles heel.  Over time, I was able to create a team that had complementary strengths and weaknesses valuing what each individual brought to the table and minimizing their pitfalls. 

While you don’t always get to choose your team, it is possible to cultivate this over time which brings me to my caveats about acceptance.  The first caveat is implied.  Sometimes accepting someone for who they are means ejecting them from the team and finding them a new home.  I believe we have all been in situations where we are the odd person out.  We don’t fit.  In this day and age, we need to check our biases.  The color of our skin, our gender orientation, religion, cultural and social background must not be used to exclude others.  In fact, this diversity of people, of ideas, and of life experience are valuable assets that we should embrace.  But after we have made sure that we are not acting on bias, if there are still challenges, sometimes the greatest acceptance of a person is to find them another team to be on.  The second caveat is that while we should accept people for who they are and what they can contribute, sometimes we have no choice but to ask something more from them.  If my teachers and parents had only asked me to live up to expectations, I might never have been able to achieve what I have so far in life.  It’s okay to expect more if people are willing to give more.  This also is a form of acceptance.  The problem is when we expect more from those who cannot give it to us or do not want to.  As fellow human beings and leaders, our job is to identify the best in every person we encounter and maybe in some way, help them be a little better.  It starts with acknowledging the person in front of us for who they are without judgement or scorn.  One of my greatest sources of growth as a human being have been my patients.  I have seen them beat terrible odds, accept mortality with grace, and teach me through their life experiences.  This has happened because I strive to accept people as them and don’t impose my biases or judgements.  In turn, they hopefully see me as a partner in helping care for them.   

The truth is that not everyone wants to exceed expectations.  Alternatively what they want to excel in may have nothing to do with you.  That’s okay.  For patients or co-workers who want to meet expectations, our job is to meet them where they are.  For those who are motivated to exceed expectations, our job is to help them get to where they want to go. 

At the end of that night in college, my friend mentioned he was in town for a few more weeks and wanted to get together again.  I told him to give me a call and see what we could work out.  He never called me but we have bumped into each other several times over the years.  We each have our own lives, families, and careers and have a good time when we do see each other.  We have each accepted each other for who we are.  For this, we gain the occasional episodes of camaraderie and in return, we lose nothing.  Wouldn’t the world be a little bit better if we could all do the same.     

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Navigating Consumer Culture in Health Care

When I take a step back from my current practice of medicine, I am struck by how much has changed in the 17 years I have been seeing patients after completing my residency.  Much of this has been driven by technology- the electronic medical record and patient access to records and communication with the health care team through portals.  I believe this has worked out both in favor of physicians and patients as we have better access to medical information during an encounter and another option to communicate with our patients. 

What is more striking to me is how much the patient-physician interaction has changed over this time period.  Let me elaborate on this further.  I’m used to seeing patients for a second or even a third opinion for certain problems.  In fact, I encourage patients to seek second opinions all the time telling them that “the doctor who does not want you to talk to another doctor is someone you should run away from”.  This interaction has not changed.  Instead, what I am seeing now more and more are patients referred to me for a problem who do not like the answer I am giving them.  I recently saw an elderly patient who was referred to me by another urologist for consideration for surgery.  Her medical condition placed her at high risk for post-operative complications and her cancer had not been adequately staged.  Even though she got an appointment with me within a week of contacting my clinic, she had been dealing with this issue for several months and when she arrived in my clinic, she expected to be scheduled for surgery immediately.  When I explained her overall medical circumstance and that I would need to perform additional testing prior to proceeding with surgery, she became irate and insisted on being scheduled for surgery without the recommended work-up.  I appreciated her frustration and acknowledged the challenges that had been placed in front of her in navigating the health system but told her I would not proceed with any intervention without completing the appropriate work-up.  When I offered her another opinion, she told me that I had to take care of this issue and that she would not see anyone else. 

Several months before this, I was referred a young man who presented to me for a surgical consultation.  He insisted on a video consultation which I was happy to oblige even though he lived and worked less than 10 minutes from my clinic.  He also requested a 12:30 appointment which is when I try to call patients back and catch up on my “in basket” between my morning and afternoon clinic and I was able to accommodate that as well.  When we connected on the video, he started off with his list of very detailed questions and requests.  While I appreciate patients being prepared for their visit, I also am interested in educating them on the disease, their options and the risks and benefits of each option before drilling down on details like surgery scheduling, surgical approach, expected recovery, time off, and long-term outcomes.  I have found that when I have 5-10 minutes to teach people about the disease process, I am able to answer 80-90% of their questions allowing them time to focus on concerns that I did not address. When I interrupted him and offered him this approach, he became upset.  I get that people want to be in control of their health care but as I answered his questions, I became concerned that he was not really asking the right questions.  When he demanded I give him a surgery date, I told him that I needed to review more information with him and asked him to come in and see me in person at the end of the day.  When he refused, I told him that I would not feel comfortable proceeding and he became upset yet again.  Ultimately, he agreed to come into clinic and we were able to have a much better interaction in person. 

I have at least one of these challenging encounters every few months.  I’m not a difficult person.  I am also not the kind of surgeon who believes that surgery is the right answer for every problem I see.  I also believe very strongly in patient-centered care.  I try to get patients in to see me in as short a time as possible and will add patients on to clinic, arrange for phone or video visits on non-clinic days, and call patients back at the end of long clinical or administrative days or on weekends.  I try to answer all questions and when I do not know the answer, I will do the research to get the right information to my patients. 

Hospitals, health systems, and payers are increasingly focused on patient experience as a metric of quality.  While there is a great deal of data on how better patient experience results in better outcomes for patients, I really struggle with how sometimes patient expectations contradict appropriateness of care.  When the Institute of Medicine outlined goals for health care delivery- safe, timely, effective, efficient, equitable, and patient-centered, I am not sure that they realized that there could be conflicts between these different priorities and that there should be a hierarchy in terms of which of these are more or less important.  Sometimes efforts to provide patient-centered care with high patient satisfaction contradict with safety and effectiveness especially when the care that is desired will not improve outcomes or is altogether inappropriate.  So as health systems shift terminology from patients to customers or clients, physicians and other healthcare professionals have to ask whether this is appropriate and really in the best interest of high-value patient-centered care?

To answer this question, there are several dimensions that we have to explore.  Unfortunately, I am exploring these issues while the shift is well underway so ultimately, the last part of my discussion will be focused on how we as physicians and healthcare professionals respond to the consumer culture taking over medicine. 

The first challenge in the patient-consumer equation rests in choice, or often the lack of choice.  As consumers, one of our powers is choice.  We can choose where we want to go out to dinner, choose from a variety of products at a grocery store, where to live, which car we want to drive, and where we want to have our health care, most of the time.  But there are many circumstances where neither the patient nor the physician has a choice about entering into a therapeutic relationship.  By law and regulation, when a patient comes to an emergency room, if that hospital has the ability to treat that problem, they have to.  That means the ER doctors have to see and care for that patient.  It also means that if I am called in for an emergent or urgent consult, I have to see and evaluate the patient and care for them if I am able.  While sometimes the patient chooses which ER to go to, they often do not if they are brought in by ambulance resulting in a care team of the physicians who are “on call”.  In larger hospitals, a patient can request another physician in that specialty but many smaller hospitals only have a single doctor providing that care leaving patients without options. 

There are other barriers to patient choice as well.  As many of us know, the pandemic has caused closures of many smaller and rural hospitals.  In many communities, there may be one hospital or clinic or no hospital for a great distance.  Even in communities with multiple hospitals or health systems, the rise of narrow networks increasingly is limiting which hospitals, physicians and clinics patients can access.  Yes, patients need to read the fine print on the health care insurance they choose but their choice is limited by their financial resources or sometimes by their employer who is offering the benefit.  If you happen to be the only doctor providing a certain type of care in a narrow network, patients have no choice but to see you.  I see this all too often when patients self-pay for a consultation but are not willing to pay for an intervention with me because their insurance will not cover an out of network provider.  As we can see, regulation, payers, and sometimes geography limit both choices for patients as consumers and the physicians who care for them. 

A second big item that challenges the notion of patient as consumer or customer is the cultural trend of skepticism of expertise.  This has become increasingly apparent with the COVID pandemic where people have questioned many of the mitigating interventions that the medical community have developed.  This includes the value of public safety measures such as masking, social distancing, and hand hygiene to strong anti-vaccine sentiment.  I won’t belabor this point because others have covered this much better than me but the countertrend has been for non-experts to advocate for treatments that have been scientifically disproven.  There are at least two randomized controlled trials of hydroxychloroquine that I am aware of that show no benefit to this medication in treating COVID.  Similarly, ivermectin has shown no benefit but led to several court cases forcing hospitals to provide this as a form of treatment to hospitalized patients. 

The common understanding is that when a customer seeks a service, they rely on the expertise of the service provider to help guide the decision.  Part of what the customer pays for is the knowledge and skill of the person they are seeking services from.  With a growing culture where people question expertise more and more, customers are attempting to dictate both what care they receive and the type of care they get.  In a purely patient-centered approach, we would give the customer what they wanted.  But in health care, this may strongly contradict safety, efficacy, efficiency, timeliness, equitability, and appropriateness.  I have patients that come to me all the time with what I view as misinformed or inappropriate requests that will not treat their problem or benefit them in the long term.  As physicians, we are expected to follow the highest level of medical evidence in our clinical recommendations and increasingly professional societies, payers, and health systems are holding us to guidelines and best practices.  What master, then, is a physician supposed to follow?  In other services, the customer is always right but in medicine, that cannot be the case because care is supposed to be based on standards and pathways rather than the desires of a patient.  The added complexity here is that unlike other services, physicians cannot simply refuse to provide care as patients, in certain circumstances, can claim abandonment.  It’s one thing for me to provide a consultation or a second opinion where the patient can walk away and consider what I have recommended and an entirely other situation when a primary care physician has a patient that is non-compliant or even combative. 

Adding to this complexity is the growing lack of civility we are seeing across our society.  It is no longer a given that patients will be respectful or use civil language during a visit.  Workplace violence is a large and relatively unrecognized problem in healthcare by the public.  The Joint Commission is now surveying hospitals on their mechanisms to mitigate workplace violence and keep our nurses, physicians, and other healthcare professionals safe, but we are at greater risk from violence from patients, families, and co-workers across the various sites that we interact with our patients.  This ranges from verbal abuse to tragic gun violence.  This ire is often directed towards non-physician staff.  When I hear about this from my nurses, clerical staff, and medical staff in clinic, I will call or speak directly to patients who are often surprised that I am addressing poor behavior with them, but I have to advocate for the people I work with every day.  I have had to fire patients from my clinic who inappropriately touched one of my staff or who were so verbally abusive that a therapeutic relationship became impossible.  While I try to drill down to what is driving the behavior- fear, anxiety, external stressors- and try to provide my patients help, there is a line where lack of civility poses a safety risk to me and my team. 

A third challenge in medicine is understanding who the actual customer is.  This is somewhat similar to my last point, but the significant difference is that my last argument was more about the patient questioning and dictating care decisions.  This point is about who actually makes the decision about the health care that is delivered.  Simply put, there are multiple stakeholders that decide what care is provided to patients.  Many times, the patient is not actually the customer.  In some cases, employers are the customers of health systems.  In other cases, insurers and especially Medicare make decisions around what healthcare patients have access to and can receive.  They do this through intermediaries like pharmacy benefit managers, third party review, and several other mechanisms that both determine coverage or decide what medications and treatments are available and by whom.  In addition, a majority of physicians are now employed and are accountable to the entity that pays their salary. 

The last bucket is a large bucket that encompasses other challenges physicians face treating patients like customers.  If I can sum it up in one statement, I would call it the generational problem.  When I finished my residency, my mentors taught me the same principles of success that they had been told- a successful physician is affable, available, and able.  To translate, to have a successful practice, a doctor needs to be nice to patients and referring doctors, readily available to take pages and phone calls when they are wanted or needed, and able to confidently deliver the care they are being asked to provide.  The challenge with this recipe for success currently is that it is at risk both from newer generations of patients and changing expectations of new physicians and other health care professionals.  Patients want health care when, where, and how they want it.  In the past, this would mean a patient would call the answering service for their doctor or the hospital operator who would then connect with the doctor on call for the group who would respond.  During the day, a patient could call clinic and be connected to a nurse or the doctor in the group seeing patients in clinic that day.  That is not good enough for our “on demand” culture expectations.  I routinely open the electronic medical record in the morning to find a patient who sent a portal message directly to me at 2 or 3 in the morning sometimes for an urgent issue that should have gone to the on-call physician.  Our clinic team routinely gets requests to switch appointment times or dates, change from in person to virtual visits, have tests ordered and performed at a local hospital or clinics outside our health system, or cancellations with requests for me to call patients back with results.  These changes place a high burden and cost on clinic staff who have to reschedule or help schedule and chase down results in different health systems taking them away from caring for the patients in front of us.  There are simply not enough hours in the day to be “available” the way current patients expect us to be. 

This is compounded by the fact that the new generation of physicians are not willing to sacrifice their time to be available in the way that their peers expect in this “on demand” culture.  They are increasingly choosing work situations where they do not work full-time, job-share, perform shift work roles, negotiate less call, and create firewalls between their work and personal lives.  I do not begrudge them of this since we have talked about work-life balance in many professions for years and this generation is doing something about it. The problem is that this leaves those of us who have grown up with the guilt of availability shouldering even more of the responsibility.  I always bring my computer when I am out of town and my pages are forwarded to my phone that reach across the country.  I will open up my electronic medical record at least a couple of times a day even when I am on vacation because I am never sure if someone is in clinic to answer patient questions.  Can we actually meet the needs of patients who view themselves as customers when those expectations are unrealistic for any human being? 

The answer is no and in addition to the pandemic, these consumer expectations are driving physicians and other healthcare professionals out of the work force because of burnout only making the problem worse.  This has been especially apparent with our nursing colleagues who are leaving their profession in droves because we are asking them to do more with less for more patients with higher demands and greater complexity. 

I know this feels like a diatribe on consumer culture in medicine.  That is not the case.  I believe in patient-centered care.  I believe in empowering patients to make informed decisions about what is best for them and shared decision making that helps patients improve their health and well-being.  I believe strongly in patient access and timeliness of care.  We learned the hard way during the pandemic that not all “elective” care is equal and that outcomes did suffer when patients did not have access to services early in the pandemic and continue to suffer because of constrained staffing in clinics and hospitals.  I also appreciate that there are social “influencers” outside of patients brief interactions with healthcare entities that we often do not understand as we try to care for patients.    

As much as possible, we need to provide patients choices and allow them to seek the best care with the best providers possible based on transparent metrics and outcomes.  But fundamentally, we must acknowledge that health care is a system that constrains certain choices and is delivered by people for other people.  Doctors, nurses, healthcare professionals, and patients already function with certain constraints, rules, and regulations and the customer model has to take that into consideration.  To support patients’ choices and voice in healthcare, I propose two options for how we may go about supporting an experience that will honor both patients and those who dedicate themselves to healing patients. 

Option 1:  Health Care Professional Bill of Rights

In response to work-place violence and burnout, many health systems and organizations have developed policies that articulate how their healthcare professionals should be treated by patients.  However, I have not seen any of this made truly transparent to patients.  Healthcare cannot be delivered without the nurses, physicians, and all other staff that have dedicated years or education and training to serve patients and we need to make sure that patients understand this as they access care.  The airline industry has worked this out.  Yes, passengers are customers but when a passenger is on a plane in a seat, there are expectations of that passenger to maintain safety during the flight for other passengers and the pilots and flight attendants.  This starts when a passenger buys a ticket and is asked questions and reminded of rules about what can and cannot be in their bags during a flight.  Before the flight begins, passengers are shown a video or instructed by the flight attendant on safety procedures that dictate the customers behavior on the flight.  There are also now laws that protect flight attendants from unruly behavior resulting in ejection from the flight.  I have created a list below and for those of you who have read this far, I would love to get your suggestions to refine this list.  It would also be great to create a video to show patients before their first visit that articulates behaviors that will result in a productive visit and keep everyone safe:

  1. Healthcare Professionals Are People.  Treat us with respect and kindness and expect the same from us.  (if you are wondering if your behavior towards others is inappropriate, ask yourself what your Mother would think of it.)
  2. Healthcare Professionals Are Experts.  You have come to us for advice and treatment.  We will listen to you but please also listen to us.  Patients have the ultimate decision about treatment, but healthcare professionals can’t be forced to deliver treatment that is ineffective or inappropriate based on best practices, guidelines, and established levels of evidence. 
  3. Violence and Abuse to Anyone in Any Healthcare Environment Will Not be Tolerated.  Mitigating Circumstances Must Be Understood and Addressed (mental health, distress, etc…) but persistent incivility and poor behavior will forfeit the medical relationship. 
  4. Respect Healthcare Professionals Time and Expect the Same from Us.  Use common sense about the right way to communicate with your healthcare team.  Understand that you may not receive an answer immediately and that answer may come from a covering member of the team. 
  5. External Entities Sometimes Dictate How and What Care We Can Deliver.  We, as healthcare professionals, will try to obtain what we consider the right tests, medications, and treatments for your care but are sometimes limited by your healthcare insurance coverage and inability to get authorization.  

Option 2:  The Uber Model of Health Care Rating

Lists of rules and rights can be hard for anyone to remember.  I was recently on a trip and ordered an Uber at the airport to take me to my hotel.  As many of you know, Uber allows you to rate your driver.  But the driver can also rate you as a customer.  I recently looked at my Uber app and found my rating as a customer which was 4.69.  Not bad but I am a type “A” person and strive to achieve the best score I can.  In the app, there is a write-up to help customers understand their rating.  These include not keeping the driver waiting when they arrive (time is money), courtesy, and safety.  In many ways, this hits upon some of the “bill of rights” statements I have included above. 

We have long been rating healthcare professionals and there are numerous websites that provide scores for us as individual physicians with comments in addition to more formal surveys that patients complete in both the ambulatory and inpatient setting (CG and H-CAHPS scores).  These validated instruments are used to provide us feedback on our individual as well as clinic and hospital performance in terms of patient experience.  The nice thing about these scores is that there is enough granularity to allow us to drill down to develop countermeasures for improvement.  That’s not the circumstance with a 5-star rating system but given what we as providers know about patient experience, a lower score on a simple scale can give us the impetus to dive deeper to try and improve. 

It would be a sea change to rate patients but coupled with clear expectations above, it could help patients understand better how their behavior and interactions with the healthcare system might impact their experience of care.  The technology is already available to be able to provide patients with a way to check their star rating.  After a visit, a doctor, nurse, or other provider could enter a score into the electronic medical record that would then post to the patient portal and be averaged with the ratings of other providers they have seen in the system.  While this will not influence everyone’s behavior, will not be accessible to those who do not use the portal and will not likely cross health systems, for those who do use the portal, it has the potential to impact behavior.  We all want to be viewed in a good light.  Peer pressure and our social nature as humans could be a powerful influence to impact behaviors that will positively effect the clinical care experience.  There are mitigating circumstances that would need to be taken into consideration and physicians and other healthcare professionals would need to be educated with clear guidelines on how they rate patients and what is in scope and out of scope of the rating.  In addition, there likely needs to be a certain number of encounters before a patient can be rated and this would eliminate rating patients who are seen only once a handful of times in the system.  I would also consider avoiding rating patients in certain encounters- the emergency room, prior to surgery/procedures, behavioral health, or labor and delivery. 

This type of model would take some political will by a health system and probably would be best to start in a completely integrated health system where the insurer and provider of care are one and the same (Kaiser?).  Alternatively, health systems could partner with large employers in a rating process of their employees. However, this could be a powerful tool for providers and patients to have discussions about how each of them feels about their interactions and discuss how to make these interactions more productive in optimizing health and wellbeing.  I would limit this to adult patients.  It could also be a way for health systems to understand how to serve patient populations via data analytics.  Are star ratings poorer for some demographic or social group because the amount of time or way the clinical encounter is set up? 

Ultimately, the consumer ship has sailed.  Health systems and individuals view the patient experience through the lens of a customer.  We as health care professionals are playing catch up and need to balance the physician (and nurse and other team members) interactions with patients in the interest of better patient care and our own wellbeing.  I believe creating rules of engagement could be this opportunity and would love to hear your thoughts. 

Going For It!

As some of you know who are regular readers, several of my family members including me figure skate.  Recently my daughter went to see Stars on Ice at Little Caesar’s Arena in Downtown Detroit.  It had all the recent Americans who participated in the Winter Olympics in Beijing who if you follow figure skating are household names.  I think everyone knows Nathan Chen who won the gold medal in the recent Olympics.  If you are interested, you can follow this link to see the list of stars: The Skaters | Stars on Ice.  While most people point to the quads and triple jumps as well as the spins that defy balance, every part of skating requires effort at that level.  The thing about skating is that you can easily tell the difference between someone who is “phoning it in” and someone who is really “going for it”.  Yes, the great skaters make their jumps and spins look easy but the moves in between distinguish between someone who is truly out there for personal joy and to entertain the crowd and those who simply are going from one technical element to the other.  It is possible to win based on the technical elements but as my coach always says, figure skating is a visual sport.  Fundamentally, to both look good and be good (which I am neither), it takes great control of your body in everything you do on the ice.  My daughter shared videos from the performance and one of my favorite skaters is Jason Brown.  He does not consistently land his quads which in this day and age takes him out of gold medal range because of how skating is scored, but he is amazing to watch.  If you are remotely interested, here is his long program from the recent Olympics: https://www.youtube.com/watch?v=W44QDl16pK0

Besides the amazing technical capability and grace, I believe what sets him apart is that he does not hold anything back.  He puts it all out there both physically and emotionally.  I would argue that this is the key to finding meaning and purpose.  Whether it is figure skating, another sport, or life in general, it is hard to achieve something meaningful when we hold back.  With so much money on the line in Professional and now College sports, I often find it more exciting to watch a high school basketball or football game where the young adults are out there for the love of the sport and competition.  Heck, even my son’s little league baseball games can be more entertaining than MLB as the kids make bold moves to steal bases and swing at bad pitches hoping to get one over the fence.  Intuitively, I believe we all know the exhilaration of really putting it all out there in the hopes of achieving something great.  I also believe we all understand that it requires effort to achieve success. 

So why do most of us hold back?  If you have read this far, most of you are screaming at me that I am being naïve.  The world is a tough place and those who put themselves out there expose themselves to failure or worse, find themselves marginalized.  Fear of failure is a good reason for why people hold back but I do not believe it is the primary reason.  I don’t believe people are fundamentally lazy but I believe the root cause that holds most of us back is that we let life beat us down and choose to hold back because it’s just too darn hard to expend the effort required to overcome the hurdles.  This may be a result of a series of failures that has exhausted a person’s reserves.  It may be that the everyday responsibilities of life just take too much time and effort to have left over energy for anything else.  And, of course, there are external forces that prevent a large portion of our population from even having the opportunity to go for it- lack of education, hunger, homelessness, poverty, systemic racism, gender bias and other forms of discrimination and hate.  The list can go on and on and certainly most of us agree that many people are never given the resources and support to be able to “go for it”. 

I read a recent article that addressed the question of how much parenting impacts the future success of our children (The One Parenting Decision That Really Matters – The Atlantic).  The conclusion was that the main parenting choice that impacted the future success of kids was what neighborhood and community a parent chose to raise their child.  As most of you know, I didn’t grow up in Ann Arbor, MI (which was sited in the article as increasing the odds of future success), but my parents made sure to find the best neighborhoods and schools every time we moved to a new city.  The interesting parallel here is that the greatest determinant of the health of an individual is the zip code they live in.  Who we surround ourselves with and what resources are available have a lot to do with our ability to go for it versus those who are held back.  Sadly, disparities in our society stack the deck against a large portion of our society. 

Which makes it all the more sad when those who have opportunities choose to settle for mediocrity.  People point to the pandemic as a cause for burnout which is the rock bottom of holding back.  But I believe before the pandemic, many of us were treading water already beaten down by the countless pressures and stresses in life.  That left so many people choosing to go through the motions of living without achieving their potential.  For physicians and other health care professionals the successive waves of electronic medical records, increased scrutiny and regulation, diminishing autonomy and control, and overwhelming patient loads for many doctors and nurses caused many of us to shrink in and focus on just getting from one day to the next.  The pandemic merely pushed us over the abyss.  It is likely we can tell a similar story for other professions. 

I’m here to tell you that holding back is not an option.  While the world has beat us all down, those of us who were given the opportunities by our families, our communities, and the advantage of resources have an obligation to get back up and go for it.  There are simply too many problems in the world to solve to squander the amazing talent and expertise that is already here.  There are some who will get back up because they are motivated by fame and fortune.  But most of us that have been knocked down are not out there to become billionaires or a household name.  I truly believe that most of us, especially in health care, went into this to make the lives of those around us better and we can’t do that if we are not even playing in the game.  I can’t promise anyone that if they “go for it” that they will succeed.  Many of us will fail and maybe never achieve our ultimate goals.  Some of us will achieve great things but most meaningful solutions were built upon the countless incremental efforts of those who came before us. 

When I get down about my lack of progress on certain initiatives and contemplate why I am putting in so much effort, I try to take a long view of where I started.  Having the broader perspective allows me to appreciate the small successes and failures over time. 

This is not a story I like to share but here it goes.  When I was 16, I failed my driver’s test three times before I finally passed.  The reasons are burned in my mind for all eternity.  The first time, I parked 2 inches too far from the curb parallel parking downtown (who needs to parallel park in the suburbs of San Antonio especially without power steering?).  The second time, they told me I signaled too late when I changed lanes.  The third time, I apparently did not keep a two car distance between me and the car in front of me.  I think it took me two months to get up the courage to take my fourth driving test.  As the examiner got in the car, he looked at me.  He was the same guy who had told me I signaled too late and, of course, reminded me of my prior failure.  At the end of the test, he stared at me stone faced and handed me my test results.  Not only had I passed but I received almost a perfect score.  Me passing a driving test may not be the most meaningful accomplishment in the world but the ability to drive safely has allowed me to both help countless friends and family as well as the freedom to explore the world.

The first thing you learn in skating is how to get up after you fall down.  Whether it is a driver’s test, sports, a job, or family responsibilities, for those of us who are able, we have an obligation to go for it every day.  A failure or a small success may be the ingredient for your or someone else’s future success. And if you can, help someone else by opening the way for them to “go for it”. 

The Physician Training Conundrum

It was rare for me to go to the operating room as an intern or second year resident.  We had what many trainees refer to as a “top heavy” program where most of our operative experience was concentrated in our senior years of training. In hindsight, I am not complaining. I learned how to be responsible, efficient and take care of really sick patients that has served me well during my career.

While my surgical training was concentrated towards the latter part of my residency, it did not mean that I was not responsible for performing procedures outside of the operating room.  I grew up in the era of “see one, do one teach one”. This started literally on day one. The interns in my program were expected to come in on the Saturday before officially starting on Sunday to “orient” to their role.  The idea is that Sunday would be less busy giving the intern a chance to acclimate to their new role. As I walked in on Saturday at 6:30 AM (rounds started one hour later on the weekend), I was greeted by a fatigued soon to be second year resident starting his chosen field of ortho the next day. He had 19 patients to round on and very little patience for me. I trailed him and the fellow as they rounded and wrote down the scut list on the rounding cards as they went rapidly between patients. At the end, the intern I would replace turned to me and said, “We have 1 hour to get the priority scut done before breakfast”, and asked me to follow him. It was there I watched for the first time how to pull out chest tubes after cardiac bypass. I took notes. I listened how he talked with the patient and then stood shocked as he yanked the tubes out, covered the holes with Vaseline gauze and placed a massive dressing over the holes.

He turned to me and said, “ Now I’m going to watch you do one and you can pull out the rest so I can go check on all the chest x-rays. Meet me in the cafeteria after you are done.” It was a requirement to check a chest x-ray after pulling these tubes to make sure there was not a pneumothorax.  I carefully replicated the steps I had watched and then talked to the patient telling him to breathe out as hard as he could when I gave the word. My first one went well except that I splattered blood over the wall of the room. My teacher applauded and then handed me a tub of peroxide wipes to clean it up because the nurses would be mad if we left a big mess.

He then left me to care for the other 3 patients. You heard me right. Left me to finish the work even though I was not technically officially on the job. Luckily, I did not harm anyone that day. He bought me breakfast and then handed me the pager. “All of the x-rays are okay. Finish all the notes and then sign out to the fellow and night coverage and go home. It will be your last night of good sleep for a year. “

That was my introduction to residency education. It didn’t get much better. When I didn’t know how to do something, I would try to look it up first and if I couldn’t figure it out, I would ask a senior resident or fellow to show me which was usually answered with a sigh and a disgruntled okay. This is how I learned how to pace patients out of atrial fibrillation or pull pacing wires. This is how I learned how to do wound care on infected sternotomies sometimes looking at a beating heart inches away. In fact, this is how I acquired most of my technical skills on each service I rotated on. The expectation was for competency and self-reliance. One senior resident started the rotation by saying, “Call me if you need me, but need me if you call me.”

Getting into the OR was not really a reprieve from this. Around 8 or 8:30 PM, there would be a page to come help close the chest on my first rotation. I would dutifully change from my whites (short white coat and white pants) into scrubs and enter the OR. There I would apply the bone goo and take these massive needles on titanium wire and help close the chest twisting the ends with plyers. It would be a constant barrage of criticism and at the end, the fellow would scrub out leaving me to transport the patient to the cardiac ICU and do sign out with a stern command to make it fast so we could round on the other patients. Only after rounding and taking care of scut could I sign out to the night call person and go home.

And so it went. As I progressed through rotations, I would occasionally get a chance to scrub on other cases as an intern. Covering ENT and neurosurgery, I learned how to do elective tracheostomies. In general surgery, I was called into the OR at 2 AM to assist with an appendectomy because all of the senior residents were occupied. In the 15 minutes I had before starting the case, I read about the case, read the resident notes on exactly what this surgeon did and then entered the room prepared. I shaved, prepped, and draped the patient before the attending entered. I had the films up. I even asked the OR to put on the music the surgeon liked. As he strolled in with me scrubbed, the first thing he said was, “ Who draped this patient?” Hoping for a rare compliment, I informed him it was me. He then explained that I had prepped too narrowly. What if it wasn’t the appendix and we had to extend the incision?

I took everything down and did it over. He then handed me the scalpel and I made the incision doing it precisely according to the notes. He didn’t stop me but he sighed so loud the next room could have heard it. As I delivered the appendix and proceeded to isolate the blood supply, he quietly spoke. “ There’s the right way to do it and then, there’s the way you’re doing it. “ He took over and completed the surgery which I watched and then left for me to close.  No explanation for where I deviated or what I did wrong. 

The rest of my 5 years of residency were not that different. I genuinely believed that this was the way that surgeons were trained. In order to do anything, the expectation was that you would be prepared for the case the way the surgeon did it. I would keep voluminous notes and even though it cut into precious sleep, I would make sure to read before every case and know the details of the patient by heart. Any sign of hesitation was viewed as a lack of competence and the attending would take over.

When I finished my training and started my fellowship and then my faculty position, I carried this model of education with me. The only difference was that I would give everyone three chances before I took over the case. Surprisingly, I was viewed by the residents as a good teacher. When they called me for a consult or to update me on patients, I told them to give me the critical information in 1-2 minutes followed by a plan. Those who had no plan, got my plan which often made more work for everyone. The residents seemed to respond to the style I had labored under. I even received the teaching award several times from the resident.

But I always knew there was a problem with this approach and over the last several years, these problems have been magnified. First, this approach is hard on me and tough for some residents. I’m not a mean person and I don’t enjoy being hyper-critical of people. While I expect people to be prepared when they come to the OR, I want the residents to learn how to be versatile surgeons that can respond to the circumstances of the surgery and not follow my exact recipe for the surgery. It’s why I harp on anatomy and technique so much more than the individual steps of the operation. It is also hard to watch certain residents fold under the barrage of criticism. I know all of them have worked so hard to get to this point and if they are not progressing it is a failure on all of us.

This model worked okay when I was a young surgeon close to the age of the residents, but is becoming increasingly less effective with a new generation that has different expectations of their training and frankly, fewer hours to train. Our program has tried to train us to be modern educators but as I mentioned in my last blog, making the investment to develop the breadth and depth of graduate medical education knowledge is a challenge given the enormous amount of information and research coming out on this and my bandwidth to dig into the resources. So instead, I try and rely on a combination of my training model with concepts of coaching and feedback that I have learned from my leadership training. My other source of how to interact and train the residents is derived from being a parent and trying to appreciate the much different life experience our trainees have had compared to me growing up in a time where cell phones, texting, and the internet were not available to be able to quickly learn about something or contact someone who could help. When I am studying with my kids, they respond better to short, high yield sessions rather than the grind I was used to. They also shut down when criticized or when they sense sarcasm. Positive reinforcement yields better results. I could act like an old man and say that we were tougher going through school but the reality is that my kids and the young men and women going through residency training now have different expectations of how to learn that we must tap into to get the best out of them.

As a side note, social media and tech are great tools for learning and knowledge but also serve as a watchdog for outdated teaching techniques. These days, every snippy comment I make in the OR has the potential to become a meme and my residents know my greatest hits of commentary which I should attribute to the physicians who trained me.

“Let’s act like we’ve done this before.”

 “Is this the same case?”

“This is not Burger King.  We don’t do it your way.” (ps- that is a Weizer original)

I am sure my residents can share my top ten greatest hits but this is not the stuff I want them to remember. I genuinely want them to have the tools to be good doctors and surgeons and not simply replicate what I do.

Another problem with our historic training model is one of external pressure. I have after 17 years in the same place, a strong referral practice and expectations from my referring doctors and self-referred patients to have the best outcomes I possibly can. In addition, there is an appropriate, but much greater focus on tracking and reporting patient outcomes with that data used by payers and often reported publicly. This makes it very hard as an attending surgeon to really give residents’ autonomy. During my training, I had a lot of opportunity to operate independently. I hope that patients did not suffer but it prepared me to function independently when I finished residency. These days, it is rare for residents to have this opportunity and as such, I find myself teaching fellows and junior faculty skills that I would have learned earlier. This doubly detracts from resident training since it pulls attention away from them. I speak with countless colleagues around the country who have a similar experience that we are having to invest a lot more in those we hire as partners before they are independent. In a world where there are pressures on both outcomes and productivity, there are some cases where newly graduated surgeons are placed in situations without good mentorship and have to sink or swim. In an employed model, mentoring someone else can impact your ability to meet productivity expectations. This is not fair to anyone. Every doctor wants to be capable for their patients. Those of us who do value being teachers want to educate those we work with to be skilled and safe surgeons.

With the challenges of generational differences, teaching that does not work for every learner, high expectations of good outcomes, and productivity pressures, not to mention compressed time to train people, it can feel like our model of training surgeons is under assault. There are of course, plenty of solutions but none of them are silver bullets. There are a lot of efforts underway to provide faculty training and education in modern teaching approaches. While I have read the articles and heard the lectures, I really lack the time or patience to change what has worked for me and patients for so long.  Like Europe, some have advocated for creating training tracks in specialties and restricting certain care to fellowship trained individuals or those who have demonstrated consistent competency in certain skills and procedures. While this sounds nice on paper, for the field of Urology there are simply not enough trained doctors to provide care to the population and decreasing the access to certain care in communities results in delays with worse outcomes. This only makes it more difficult for patients to get the care they need.

Like my last blog where I emphasized the need for academic medicine to truly value the clinician, a similar emphasis needs to be placed on the educator. Many times, the great surgeon or clinician is the great educator but doing both can be hard to juggle. The faculty that the residents all want to work with often have large, busy practices. In this day and age, that means more EMR work with now fewer resources. When I was a resident, I always had a better chance of getting to operate if I had seen the patient in clinic which indirectly meant that faculty member got additional support for seeing patients in clinic. I can’t remember the last time I saw a resident in clinic and I’m not blaming them. There are too few of them and too many faculty for everything to be covered. It also does not help them to see 100 discussions on prostate cancer treatment options so there is a law of diminishing returns to spending too much time in clinic. Which leaves the attending spending a lot more time having to do the many many clerical tasks associated with routine care. That combined with the need to be productive can make teaching feel like a burden when it may be one of the most meaningful things we do in academic medicine with the potential to improve the lives of many other people as these trainees go forth and care for patients around the country.

While the clinician and educator don’t always go hand in hand, there is a clear synergy there and medical schools and health systems need to think about how to support that model while maintaining the productivity of these clinicians in the interest of patient access and quality care. The simplest solution is to identify the core group of clinician educators within a Department or program. This would allow the program to invest in these clinician educators to make them even better as well as return to a model where residents spend more time with fewer people to allow for investment by the faculty in the residents skill set. I find it a challenge when I am spending two months with a resident who sees me once a week to impart my fundamentals to them and get them to complete a surgery skin to close. It’s just not enough time since each resident starts at a slightly different point and learns at a different pace. A smaller pool of dedicated clinician educators would support more meaningful training. In academics, we often see the less clinical people asking for more resident support for their self interest and not necessarily in the interest of resident education.

The other piece is to reward clinician educators for this work. Funding of graduate medical education by CMS is archaic and Byzantine. CMS reimburses hospitals for the trainees and through complex formulas, alters their reimbursement to the hospitals for Medicare patients to support the infrastructure of GME. It costs money to run GME programs but it feels like there is an opportunity to improve both the quality and invest in the types of doctors that patients need if CMS were to contemplate funding GME like it is trying to do with value based care. GME programs producing well trained graduates in areas of need would be reimbursed more than other programs. This additional reimbursement could be used to pay effective clinician educators more for the investment of time they have made to support resident education.

The last idea I think is controversial. Academic medicine has a tripartite mission of teaching, research, and clinical care and medical schools still hope they are training triple threat people who will excel in all three areas. I hope that I have made a solid argument that the body of knowledge is too large for this to be a reality except for a very few rare almost super humans. If that is the case, what should be the primary aim of the medical school in the Academic Medical System? Keeping it simple, you would think that it would focus on training medical students and other post graduates. First, that is not their only aim and a lot of investment goes into funding and supporting research and graduate student biomedical education. How much of the budget should be invested in the latter aspect and if it does not come from the medical school, where should it come from? I don’t have a great answer but it is clear that not enough is invested in those who train the next generation. Second, are medical schools investing in the right teachers and training? While medical school curriculums have evolved dramatically and are incorporating evolving bodies of knowledge in learning health sciences, health services research, population health, health equity as well as scientific advances, there is still this focus on a didactic faculty with secondary thought given to clinical faculty who incorporate teaching into their overall activity. Is this the right model? Should we be shifting more resources towards clinician educators who can provide depth in their specialty and some breadth from experience and their other activities to mold the next generation? My gut says that the fundamental assumptions need to be challenged if we want to truly train the best clinicians of the future. What will it take for us to think out of this box?

I’ll finish where I started. I know the way I learned is not the way we need to teach this or future generations of physicians. While all the other pressures that are placed on me and the many people just like me have taxed our capacity to train others, I still get a big thrill when I see a resident “get it” and work their way through a case not exactly the way I would do it but relying on fundamentals I have tried to impart. In order to do justice to those who want to dedicate themselves to caring for patients and teaching others to do so, we need to change the system to invest in and value them. If we can do that, we can leave a lasting legacy of great future physicians that will outshine the care we provide today. Thanks

Academic Medicine 2.0

I’ve spent almost my entire career as a physician in academic medicine.  It is not where I originally thought I would end up.  When I entered medical school, I had a sense that I wanted to be a surgeon but it wasn’t until my clinical rotations that I started to narrow my options.  What started me down my current path as a Urologic Oncologist was a process of elimination.  I learned quickly that I did not have the temperament or interest to be an internist or a medical specialist.  I also learned on each successive rotation that I did not have the makings of a pediatrician, a gynecologist, or pathologist.  I won’t get into the nitty gritty details but suffice it to say, I ultimately chose urology because I found meaning in caring for these patients and a tribe of like-minded clinicians. 

Once I made this critical decision, I had the impression that one day, I would finish my training and join a group and spend my career managing urologic diseases.  This guided my efforts during the early part of my training.  What set me on a different path was the appeal of mastery.  I wanted to be the best at some particular aspect of the universe of Urologic care.  Unlike some people who get drawn into academics because of research or the motivation to teach the next generation, my interest was in the pursuit of clinical expertise that I thought was not possible practicing in an environment that required someone to have to see the spectrum of urologic care.  But even when I did a fellowship, my intention was not to remain in academics but rather to find a group or practice where I could be the “go to” person for Urologic Oncology. 

But during my fellowship, my thought process evolved.  I realized that there was an opportunity to impact the way we care for patients more than one patient at a time.  So I was lucky enough to stay where I completed my fellowship and I was also fortunate that my Department invested in me by allowing me to pursue a Masters in Clinical Research and the opportunity to work with fabulous residents.  But despite doing research and publishing and spending a lot of time training residents and fellows, I always felt that caring for patients was my primary function. 

In the world of academic medicine, being a dedicated clinician is not the pathway to success.  What gets you promoted from Assistant to Associate and then to full Professor is publications, grant funding, and a national reputation.  Yes, this has evolved especially for those like myself who are on a non-tenured track but underlying the veneer remains the traditional model of academic success.  You might sense a strain of bitterness in my statement and while I once was bitter about feeling like a second class citizen in the Academic world, my thoughts have evolved significantly for two reasons. 

First, academic medicine and medical schools serve a vital role in the overall delivery of health care.  While most clinical care is delivered outside of academic institutions, innovation comes from those spend their careers in these organizations.  Innovation is how we move the field of medicine forward.  Whether it is discovery of new drugs, devices or surgeries/procedures, developing new ways to care for patients, or evolving better models of care that consider population health, social influencers of health, and value in the care we deliver, academic health systems invest in peoples’ time and resources to be able to answer big questions.  Some of you may read this and say that non-academic groups are also doing research and that is true.  Many health systems and medical groups are engaged in clinical research, improving care delivery, and other forms of innovation.  The difference is one of scale but also the focus.  Efforts outside of academia, by necessity, have an agenda.  Sometimes it is in support of the clinical mission.  Offering clinical trials in the community setting provides access to patients for innovative care but it is also a way for that organization to differentiate themselves and drive market share.  There is nothing wrong with this as often this is a win-win for patients and the organization.  And while there is a component of this for academic organizations, the scale and investment in innovation means that a large portion of efforts by academicians is in the pursuit of knowledge and discovery that may never go anywhere.  This is not something that most non-academic institutions can support.  So while a person who predominantly has delivered care and been involved in clinical operational leadership may feel like a second class citizen, I know that we all benefit from the focus of academic medical care on innovation and discovery.  It is a worthwhile investment for us all. 

The second reason for not being resentful is that the rules of the game have changed.  Given the enormous financial pressures on health systems from increasing payer oversight, decreased payments, and growing regulatory burden, academic health systems have had to learn how to provide safe, effective, efficient, timely, and patient centered care like every other health care delivery system.  In some ways, they have had more pressure to deliver on this as often academic systems rely on clinical revenue to support the research and education missions.  Academic health systems do not sit on their profit margins.  That margin is rolled back into improving clinical care delivery, supporting the education of the next generation of nurses, physicians, APPs, and other allied health professionals, and supporting research efforts for early career investigators, seed money for funding smaller ideas, and gaps in funding for established researchers between grants. The non-profit status of most health care institutions is a valuable public investment.  

This means fundamentally, that now, more than ever, academic health systems need dedicated clinicians to allow them to deliver the same high value, patient-centered care that every other health system must do.  In some ways, academic organizations need to do it better as so much of the other parts of the system depend on margin from the clinical operations.  This is an exceedingly challenging task given several factors.  First, the patient-consumer has very high expectations that may directly conflict with the competing interests of the academic physician.  In this day and age, patients expect immediate access and responses that have only escalated with the rise of patient portals and non-academic organizations focus on improving access and expertise to accommodate those same patients.  It’s simply not possible to expect a physician who has research grant funding and associated effort as well as potentially teaching and administrative responsibilities to have enough clinical access to accommodate patients in a timely fashion.  The model of academic success values research, grant funding, and national recognition (translation- traveling and speaking at meetings or involvement in national organizations pre-pandemic) and while that physician may be the expert needed by that patient, access may be poor because they spend only a limited time in clinic seeing patients.  In some academic institutions, wait lists can be months for a patient to see an expert while that patient suffers from symptoms or the uncertainty of their diagnosis.  For patients with financial resources, they can travel to seek care in a more timely fashion.  But for those patients who already have more difficulty accessing health care, this can be an insurmountable barrier. 

The second reason is that like research and education, the delivery of clinical care and clinical operations has become exceedingly complex and requires expertise.  As such, it is difficult for a physician who has invested heavily in their research and/or education, credentials and performance to be expected to be facile in clinical care delivery not to mention keep up with the massive amounts of clinical knowledge intended to improve clinical care.  Physicians who spend a small amount of their time in clinical activity often feel overwhelmed not only by navigating the electronic medical record which is updated routinely but also by changes to clinical care guidelines at the institution or from the professional society.  Not to mention the challenge of knowing who to refer a particular patient to for a specific problem, what test to order, what new test results may mean, who to communicate with when they have a question about results and interpretation or if they have problems in clinic, the hospital, or with the myriad electronic systems we as clinicians have to interface with every day.  This doesn’t even include having a working knowledge of the clinical enterprise of the organization and what it means to everyday practice if you want something changed or improved or being up to date in terms of safety culture, quality initiatives, and regulatory changes from Medicare, TJC or other local, state, or federal regulatory bodies. 

When I first started my career, the goal was to be a triple threat- a great educator, a successful researcher, and a star clinician.  As human understanding evolves, the complexity of that knowledge increases and so too does the barrier for mastery.  We haven’t even talked about education which I will write about soon but the cliff notes is that the science on successful medical education has evolved and most experienced clinicians are not equipped to be successful educators with our current learners. There is a limited pathway for people to excel in all parts of the academic mission.

As my career has evolved, I have gravitated to splitting my time between clinical care and clinical operational leadership.  This has been a natural transition for me because I believe understanding the structure of the clinical enterprise both allows me to navigate it better as a clinician but also affords me the opportunity to improve it to make it easier for all clinicians to have a chance to delivery excellent, patient-centered care.  I believe that academic health systems that want to be successful in the future need to contemplate the challenges above and address them.  I don’t pretend to have all the answers but have a few ideas to throw out into the world and hope someone will engage with me in this thought experiment. 

First, academic health systems need to find a way to eliminate the “second class” citizenship of predominantly clinical faculty.  I know that in most places, there is a clinical promotions track and I am fortunate to have progressed on that track. Despite my success, I fundamentally feel that the organization does not view me as valuable as a tenured faculty.  The solution is to either eliminate tenure or to expand the ability to obtain tenure to our most valued clinicians.  While tenure may mean a lot less than it used to especially in academic medicine, it still signifies a commitment by the organization to financially support that faculty and that they are valued so much that it is extremely difficult to fire them.  Clinical faculty are “at will” employees and can be let go without cause.  Acknowledging the complexity of what it takes to be a expert clinician by affording them a similar pathway would go a long way to supporting the clinical mission. 

The second point is dependent on the first.  An organization that figures out how to truly value clinical faculty will be able to recruit the most talented and dedicated clinicians to their ranks bolstering the clinical enterprise. For those who are drawn to this world, money is not the most important criteria.  The key here is how not to dilute the research and education missions.  An academic organization that is comprised mostly of clinicians fails to meet the societal need and investment in innovation and discovery that is its valued place.  As such, an organization that would actually contemplate this would have to evaluate its work force.  This is going to be different dependent on the Department or service line and also the local, regional, and national needs of patients.  Given the amazing amount of data we have now, though, it should be possible to look at a Department or service line and understand what the percentage of dedicated clinicians should be to allow us to meet both patient and operational priorities as well as support our academic and teaching missions.  There are several items that need to be incorporated into the model.  First, it is likely that the clinical percentage needs to be inflated to account for physician operational leadership.  We don’t want to draw operational leaders from our best researchers or educators as they are not the most expert at clinical care delivery.  We want to draw operational leaders from the clinical ranks.  These are the doctors that can influence, understand the potential pain points of decisions, and also have to live with the consequences of their choices.  Second, we have to account for unintended consequences.  There will be researchers and educators who do remain excellent clinicians and potentially feel more engaged in clinical work.  Our current model of increasing clinical access relies on asking those clinicians that dedicate themselves to research and education to increase their clinical activity.  This may work in the short term but leads to resentment detracting from other activities or compensation gaps.  Designing a workforce of a service line or group that values the complexity of expertise in each space, should improve engagement from all as they will feel supported with both time and effort in what they are passionate about.  It will also be necessary for Departments or service lines to account for people who want to shift focus.  We can’t simply fill clinical ranks with people who don’t progress in their research or other non-clinical endeavors. 

The last point is controversial (maybe all of this is controversial and I want to emphasize these are my independent opinions).  Our biggest gap in health care delivery is primary care.  This is because medical schools are producing physicians who gravitate toward specialty care.  A great deal of population health strategies and value-based care depend on an integrated primary care/ambulatory enterprise.  Because we have a supply and demand issue, most academic health systems struggle to provide access for primary care.  The fundamental question is whether to double down on developing a robust primary care infrastructure or outsource.  APPs have been around a long time to augment clinical care delivery.  Several studies demonstrate that APPs functioning independently in primary care utilize more resources and deliver care at a higher cost than a physician (more tests, more referrals to ER, more specialty referrals).  One way around this is to take a model we already have and employ it in primary care.  In the OR, an anesthesiologist directs care in 3-4 rooms but there is a CRNA that is in each room.  While laws have changed to allow CRNAs to practice independently, I think you see my point.  A physician can serve as a team lead to a number of APPs and the team shares the panel with clinical oversight of a physician. 

But if we cannot develop a scalable model of academic primary care, then the solution is partnering with others (Walmart, Walgreens, CVS?) and focusing on solidifying and expanding specialty care and leveraging technology (telemedicine) to wrap around our primary care partner.  This would allow direction of appropriate high complexity care to the academic medical center. 

Ideas need to be tested and certainly what I have presented today are models that require investigation.  That being said, the future success of academic health care requires the voices of all of us who are passionate about improving the health and well-being of those we serve.  Its time for academic medicine to value and listen to the voices of everyone that chooses to dedicate themselves and their expertise to the mission.  Please do not hesitate to share your thoughts with me. 

Captain Obvious

I believe there was one point in my life where I labored under a false assumption that I had hidden powers or capabilities that had yet to be discovered. I don’t think my feeling was unique. Many of us dream of being special in some way.

Like many kids growing up in the 80s, I occupied a lot of my time reading and trading comic books. I never really liked Superman. In a land of unrealistic characters, he seemed the most unrealistic. Being able to fly, shoot laser beams out of his eyes, possess superhuman strength, and deflect bullets seemed over the top. While he did have his vulnerabilities, it was hard to imagine stopping him with a small amount of rare kryptonite. Sounds more like a cryptocurrency than a chemical substance.

I gravitated toward Spider-Man.  While I would not buy into the whole radioactive spider bite imparting supernatural powers now, it had a sense of plausibility to my 10-year-old self.  In addition, the fact that he developed the substance to make his spider webs and the “web” shooters himself made his supernatural abilities seem attainable to me.  Even the most recent version of Spider-Man retains a sense of “reality” powered by the tech of Stark Industries.    

While I never quiet gave up hope, each passing year has dimmed the possibility of me identifying some hidden supernatural talent.  What really appealed to me about Spider-Man was his real-life.  The fact that he was a good student, interested in science, and was a photographer for the Daily Bugle somehow made his “real” life seem interesting as well.  I guess I only figured out now that Superman and Spider-Man were connected to journalism so they could be close to information that would allow them to fight crime. 

As I grew up, my attention turned to identifying “real” powers that would allow me to make the world a better place.  Medicine was actually not my first choice.  In 7th grade, I took a journalism elective and wrote for the middle school paper.  My parents never discouraged me from pursuing my dreams but I am a child of immigrants and having a practical career that would allow me to earn a good living was never far from my mind.  But the one thing that journalism satisfied was my interest in asking questions.  I never lost that inquisitive nature that drives every parent of a 5-year-old crazy.  In elementary and middle school, I would always ask “why?”.  I never accepted any piece of information at face value.  This did not endear me to some of my teachers and friends.  In 9th grade English, we spent a semester reading the Odyssey and other Greek mythology where my teacher heavily relied on Joseph Campbell’s The Hero With a Thousand Faces to direct our thinking and discussion.  If you are not familiar with this, Campbell studied countless hero myths and identified five common stages that run through these stories.  To my teacher, this was gospel.  For me, this was an opportunity to challenge commonly held knowledge.  My argument was that this archetype was a product of Western culture and there were plenty of scenarios outside of this where heroes did not follow the five stages outlined by Campbell.  I still have the paper I wrote challenging this with at least several examples.  While I got a good grade on this (and was probably wrong), she wrote comments that were equally as long as my paper disproving my argument.  She taught me for two years and we stayed in touch long after high school. 

But I didn’t only drive teachers crazy.  I spent four years in speech and debate in high school.  In our weekly meetings, people would bring arguments they developed to the group.  They served as a library that all of us could use based on the topic we were required to debate during competitions.  I would always be the one who would try to challenge assumptions and ask “why?”.  Even when the answer was obvious to everyone else, I had a great need to understand what drove people to think certain ways and believe certain things. 

When I went to college, I made a decision to pursue medicine but I also decided that I would not take the same route to get there as everyone else.  Sure, I took all my pre-requisite classes and even flirted with the idea of majoring in chemistry.  But what appealed to me most was studying history.  What I liked most about my history classes is that there were often multiple sources to explain events and various interpretations.  There was a “truth” out there to be found; but it could only be found by going to source information and wading through various expert interpretations to try and get close to what actually happened.  My favorite classes were the small seminars where we would debate various interpretations of historical arch’s and try to uncover the biases in the sources and authors. 

More than anything, I have carried this inquisitive nature with me as I have progressed in my career.  In medical school, I would often question why we chose to treat something one way versus another.  I would want to see the evidence and randomized controlled trials.  I have always been uncomfortable with expert opinions and when reviewing research articles, I spend a great deal of time identifying the biases in the study that may impact the generalizability of the findings. 

In some ways, I believe that this aspect of my nature has always been my “superpower”.  In college, one of my fraternity brothers used to call me Captain Obvious because I would always point out something that everyone knew but no one was willing to talk about.  When I was president of my fraternity, we had several brothers running a small marijuana business out of their rooms.  Everyone knew this but looked away because, in their minds, it wasn’t really hurting anyone and it was none of their business.  What I knew from attending national meetings of the fraternity as well as University meetings was that chapters were being shut down for activities like this.  In my four years in the fraternity, we had grown the membership from 17 to 55 and I had invested a lot of time and effort in making this a viable group on campus.  Early on in my tenure, at one of our weekly meetings, I asked whether anyone was selling drugs in fraternity space.  There was silence in the room.  Everyone looked uncomfortable.  Eventually one brother spoke up and asked what the big deal was.  I said that I didn’t care who was smoking it but selling it in our shared space had to stop.  I pulled out our bylaws that specifically prohibited illegal activity in fraternity space not to mention campus rules that covered us.  We even took a vote in which 65% of the brothers supported stopping this business venture in fraternity space.  Next, one of the brothers added an amendment to set a date in one month to discontinue the activity.  Another brother then added a friendly amendment that this would be enforced by removing membership if there was not compliance. 

I don’t know if they stopped selling but they did stop selling out of their rooms.  One month later, another Chapter of our fraternity on another campus was kicked out for similar activities and I felt vindicated.  It was then that my title as Captain Obvious stuck. 

I don’t have a fancy costume.  I don’t have cool gadgets.  I don’t even have a sidekick.  But what I do have is a willingness to ask questions when something does not make sense even when it is not in my political interest.  But this is a superpower we all need to wield.  I’m reading a book right now called The Voltage Effect by John List.  The book is about why many good ideas fail to scale and how to avoid trying to scale ideas that are doomed to failure.  In the book, he gives the example of the DARE (Drug Abuse Resistance Education) program.  Again, as a child of the 80s, we were all exposed to this program.  It started with Nancy Reagan’s “Just Say No” to drugs and evolved into the DARE program which was rolled out nationally as a strategy to prevent kids from experimenting with drugs in the first place.  The program was based on a pilot in Hawaii and Los Angeles that showed promising results.  A significant amount of tax payers dollars were spent ramping up the program only to find out that in some cases, the program actually increased experimentation amongst certain groups.  The failure here was that no one examined the biases in the original data to understand that the pilot groups were not representative of the overall target population.  Asking the tough questions up front could have saved millions of dollars.  More importantly, programs that might have worked better never got the resources they needed. 

But asking tough questions is not only about preventing costly mistakes.  It’s also important for us to question and examine things that we take for granted.  Whenever I hear something like, “because that’s the way we have always done this,” it seems like a prime opportunity to try and understand why.  Maybe it is the best way to do something but maybe culture and history are preventing us from doing something better.  Having a questioning attitude is a fundamental aspect of high reliability and a key to making health care safer.  Breaking down hierarchy by allowing everyone to ask questions when they do not understand or something seems wrong gives all of us the opportunity to prevent patients from suffering bad outcomes.  We have to be willing to challenge authority and ask tough questions if we really believe that protecting patients is our top priority. 

I’ve been in a lot of meetings where I ask the painful questions that everyone is thinking but not willing to point out.  It has not scored me a lot of points in some arenas where leaders are looking for confirmation and not critique.  Sometimes I am met with dead air and realize that I cannot influence the trajectory of a decision but other times, I help open the flood gates of a meaningful conversation that help leaders and the group make better decisions.  In another book I recently read called The Culture Code by Daniel Coyle (when I say read I mean audiobook driving back and forth to work or Up North to visit my daughter), he describes the creative process at Pixar.  Every day, all of Pixar gets together to review the footage created the day before on various projects.  Anyone in the group is allowed to ask questions and provide commentary.  According to Coyle, most Pixar projects start off bad- bad stories with flat characters.  But the process of open dialogue and critique is what helps refine the creative process and is what has resulted in countless box office successes and academy awards. 

While not everyone needs to be Captain Obvious, we all need to channel some of this superpower to challenge the assumptions of the world around us and make it a little better each day by seeking to understand better.  This may be obvious as well but if we are going to ask more questions, we need to listen to the answers.  I didn’t do that in high school when I was questioning the hero archetype (which is actually pretty universal) and I still have to work hard to do that now.  If your superpower is listening, maybe we can team up? 

While real superheroes don’t exist, we all can develop our super powers.  Having an inquisitive nature may be mine but there are other equally important powers that support a healthy, open,  transparent, and innovative culture that values not only the people we serve, but the people who show up to work every day and provide their experience and expertise that allows us all to accomplish our goals.  Take the time to recognize your super power and if you can’t think of one, don’t be afraid to go out and develop it.  You don’t have to be bitten by a radioactive spider to make a difference. 

Keep What’s Valuable

I think many of you would agree with me.  The world, and in particular, health care seem overwhelming.  At the beginning of the pandemic, the world shut done.  While this had serious negative consequences on the economy, it at least afforded us all the opportunity to focus on managing the pandemic and keeping each other and patients safe.  As the course of the pandemic has evolved and we have better resources to screen, test, prevent (vaccines) and mitigate the risks of COVID 19 (adequate PPE), we are now simultaneously trying to manage subsequent surges of COVID 19 while continuing necessary clinical care.  This has been exacerbated by a wave of patients flooding the ER and clinics with sequelae of poorly managed chronic disease or new illness that we normally would have seen at an earlier stage making diagnosis and treatment more complicated.  There are many factors that explain this “perfect storm” and include staffing shortages across the health care continuum, patient choice in delaying care because of the pandemic, resistance of part of the population to public health measures, and for many of us, a generalized fatigue with the pandemic.  These factors build on each other to make circumstances worse as we see the great resignation, retirement, and migration occurring amongst employees in all sectors of the economy, and more staff developing and exposing others to COVID (including patients) making staffing issues even worse.  Many hospitals and health care organizations are buckling under the strain of high volumes of medical and COVID care along with a staffing crisis that won’t be solved by more money. 

Even before the pandemic, health care was becoming increasingly onerous to staff, nurses, and providers.  Whether internally from the organization or externally from payers or other regulatory bodies, everywhere we turn there are more requirements placed on all of us to accomplish the same tasks.  Let me give you a small example.  Ten years ago, when I saw a person in clinic and wanted to schedule them for the OR, I talked to my scheduler at the end of the day or the next morning and gave them a list of who needed to be scheduled and for what.  This past Thursday, I saw one patient as a video visit who needed surgery.  They struggled with the video and I called them and talked them through how to make it work.  Next, the films were not available so I had to step out of the room and ask my medical assistant to call the hospital so that the images could be sent via VPN.  Already running behind, I then spent 15 minutes discussing options and reviewing potential risks and benefits.  Family was with the patient and they had several questions.  By the time I was done with the visit, I had three patients waiting in clinic and had not completed any of my documentation.  By the time I finished clinic at 5:30 PM, I then had to check my email that I had neglected for the day, make several phone calls, and pick up my son from practice.  After helping everyone with homework and eating dinner, I sat down at 9 PM to click through meaningful use, complete my notes, and place orders for my cases.  I got through about ½ of my notes by 11:30 PM and called it quits and spent another 2.5 hours the following evening calling back patients, answering portal messages, and completing notes. 

This summary is not intended for anyone to feel pity for me.  Many of us go through this.  Some of you are much more efficient than me and can complete everything during clinic or have figured out a way to make your clinical practice very efficient.  I would say that I am moderately efficient but have enough competing interests and don’t do that well with multitasking and this is the best I am going to get.  My point is that we have continued to add more and more to the plate of everyone in healthcare without clear relevance to the patient or the provider.  I’ve written about this previously but over the weekend I had something of an epiphany as I thought about the extreme duress I see many staff, nurses, and providers buckling under in our current health care environment.  How do we figure out what to stop doing so we can make things better? 

I want to start out with a caveat.  First, electronic medical records are a great thing.  They have improved our ability to provide safe care by reducing transcription error and have allowed better access to information to patients across the health care continuum.  Take for example imaging.  Even when I don’t have a CT scan available to me, 95% of the time, I can get it through the other organization sending it through a VPN to a viewer system so that I can make decisions in real time.  In the past, patients would show up with discs that were hard to open or even in the more distant past, sheets of x-rays that had to be looked at on a lightbox.  Or even worse, I had to send the patient away and have the images Fed-ex’ed to me and then call the patient back to continue our discussion. 

Second, the intention of our health systems, payers, and regulatory bodies is more good than bad.  Sure, everyone is trying to contain costs and that pressure seems to rest on the people doing the work, but for those organizations that are driven by a value proposition, cost containment is only one component of the picture.  Many of these efforts are focused on the STEEEP objectives that were outlined in the Institute of Medicine report- safe, timely, efficient, effective, equitable, and patient-centered care.  The big question for all of us to answer is how do we move toward a goal of value-based care without crushing the system and those who deliver the care.  One clue lies in our current staffing crisis. 

As most of us know, our ability to care for the increased volume of patients has been constrained by staffing shortages.  Over the last several weeks, I have spoken to other CMOs both within the Trinity System and outside our system and they are all experiencing the same issues.  We can’t keep up financially with the market for labor.  Nurses can make much more and work less taking a travel contract than staying with the organization that they have worked at for years.  In some cases, these nurses take a travel contract for much more than what the organization normally pays and are placed at the hospital they normally work at.  Similarly, other job categories can make more in service or food industries with lower risk than staying at their job at the hospital even for more financial compensation. 

The answer to our troubles in health care is giving people more time back to themselves.  There are several ways that this can be done.  First, we can hire more people if we can find them.  The biggest problem with this is that hiring more people with associated benefits, training, etc… is not sustainable financially for any organization.  When we talk to younger employees, they want it all- good pay, good benefits, and flexible and good hours so that they can pursue other activities in life. 

The other solution is to try and reduce the amount of work that people are doing in their jobs.  This makes sense because if people are allowed to focus their efforts on meaningful work and eliminate activities that do not add value to the task, themselves, or the patient, then this would result in reduced effort with hopefully the same or even better outcome.  This is not a novel solution.  If you have ever studied Lean or other quality improvement systems, they talk about reducing waste.  That waste can be in the form of supplies, but it can also be in the form of employee or customer time.  You may be more familiar with a popular representative of this concept.  About a year ago, my wife watched the series Tidying Up with Marie Kondo.  Marie Kondo is a Japanese consultant who has built a career on helping others organize their lives and personal items.  I don’t typically watch these types of programs (I prefer fiction when I am in my leisure time) but I sat through one episode thinking about how these same concepts apply to the work we do in health care.  The idea is not necessarily how to determine what you want to get rid of but rather what you want to keep and then eliminate the rest. 

And there is the epiphany.  How do we examine what we do and determine what is valuable to keep doing and try to eliminate activities that don’t add value.  While simple in concept, the reality is harder than it sounds.  First, we all have to agree with what defines value and because there are multiple stakeholders in health care, there are competing interests.  But one place that we can start is agreeing on values and how values apply in health care.  From a health care economics standpoint, value is simply Appropriateness of care x Quality/Cost.  The STEEEP criteria further refine both appropriateness and quality ensuring that our care is safe, timely, efficient, effective, equitable, and patient centered.  I think that if you looked at a lot of Health System or Hospital Vision, Mission, and Value statements, you would find that there is very little conflict between these criteria and the individual organizations.  Organization A may talk about Stewardship and this aligns with efficiency and cost.  Organization B might incorporate innovation into their values which is critical to improving safety and the effectiveness of the care we deliver. 

Let’s take, for argument’s sake, that the STEEEP criteria serve as our universe of value in health care.  The next step is to keep the activities that support these values.  Who decides what to keep?  That is our next tricky question but fundamentally it should be the people delivering the care and the patients receiving it.  I believe most of us know the right things to do to care for patients.  The problem is that we have abdicated control to payers and policy when it comes to care delivery.  That’s a bold and contentious statement but I am going to flesh it out further.  As a physician leader, it is important to maintain the integrity of clinical care while engaging in the broader process of health care delivery.  I believe many physician leaders do this but the further we get away from hands on patient care, the more we assume the mantle of administrative priorities.  Those administrative priorities are important- they are what keeps the lights on and keep us out of trouble BUT without the constant reference to the values and the why, a physician leader and the overall organization can drift into activities that become counterproductive. 

Its hard to untangle what we are already doing but the first place an organization can start is to have the front-line health care delivery folks weigh in when a new process or activity is going to be added.  Does it meet our values?  Will it improve patient care or provider care?  If it does, then the next question is what are we going to stop doing to make room for this new activity?  This is not a zero sum game because adding a new process that gets us to better care is additive while taking something away that does not need to be done any longer is also additive.  Once we build the muscle for new activity, then we need to break down our current work and decide what adds value and see where we can eliminate those areas that do not.  This allows us to both give people back time which I believe is the most valuable commodity in the current work force and also allow people to devote more time to the valuable activities which helps us provide safer, more effective, more efficient, more equitable, and timelier, and more patient-centered care. 

Of course, there is an elephant in the room and that is that a lot of what we do and how we do it is dictated by payers, policy, regulation, and even law.  Even though I’ve done my e-learning on infection prevention or fire safety every year for the last 20 years, I can’t stop doing it because it is a requirement.  I can’t stop doing my peer to peer calls for denials because either my patient won’t get the scan or test I think they need or they will get a huge bill for that service that insurance won’t cover.  Rightsizing the regulatory burden requires a different approach.  We all have memberships in professional societies.  Those organizations are supposed to advocate for their members.  This has done us all a disservice because it has made physicians look like we are looking after our best interests over our patients.  We need to pressure our Medical leadership to focus on the values outlined above to force discussions on how new and existing policy and regulation improve the value proposition and develop mechanisms to eliminate policies and regulations that don’t accomplish these goals.  Leveraging other organizations such as State/County Medical Societies, interactions with elected officials, and even leveraging the lobbying arms of various medical organizations to be the champion of STEEEP and value-based care and away from self-interest will allow us to simplify the way we deliver care to focus on our time and effort that benefits patients and eliminating activities that only add wasted time and effort to the system.  If a hospital or health system could accomplish this in collaboration with their physicians, providers, and staff, they would be one of the most desirable places to work and most sought after for patient care.  I’ll be honest, I may have the idea but lack the experience to start this but if you are interested and have ideas, please reach out to me. 

Battling the Confirmation Bias Underlying the COVID Vaccine Debate

The following views and opinions are solely my own and do not reflect the opinion of any organization I am affiliated with.

I had some time off recently and had to do a lot of driving.  As some of you know, that usually means that I listen to public radio but when the reception is not good or I just want to listen to something else, I turn to podcasts.  I recently found a really interesting podcast called You’re Wrong About which is hosted by Michael Hobbes and Sarah Marshall who are both journalists.  In these podcasts, they take big news stories or tropes from over the past several decades and examine them to dispel the myths.  The amazing thing about their analysis is that they don’t dig deeper to find new sources of information but rather re-examine the existing evidence where they expose the shaky conclusions and culture biases that led to these commonly held points of view.  Their topics range from the misunderstanding of “crack babies” in the 1990s to an analysis of the “After School Special” to more weighty topics such as the anti-vaccination movement. 

One of the common themes that really resonated with me in these podcasts is the idea that in order for people to pay attention to the “news”, we have to sensationalize a story by making it controversial, fantastical or by playing on human emotion.  The problem with this approach is that this creates a single dimensional view of the world when, in fact, the reality is much more nuanced.  Talking about the nuance does not get people’s attention in this age of sound bites and “on demand”. 

Now I love a good story just as much as anyone.  Storytelling has been around ever since humans formed groups.  Stories were a way for people to establish cultural norms and influence behavior.  While the tools we have available to us now to tell a story have exploded, the fundamentals remain the same.  A compelling story has a good plot, characters that the audience can relate to, and some sort of resolution.  I’m sure I am missing some things and I am certainly no expert but the key piece I find as a physician leader is that sharing stories with others connects people in a way that a PowerPoint presentation of facts and figures cannot.  The ability to take information and make it relevant to others is the power of a good story. 

I’m not telling you something you don’t already know and the biggest problem with this powerful tool is that everyone else knows it too.  Because of that, people have taken the opportunity to share and connect with others and turned this into a tool to influence and manipulate others.  Trying to influence others is not necessarily a bad thing but when influence turns into manipulation, we accelerate the societal fracture we are experiencing.  We are all both victims and complicit in this.  Our collaboration with this fracture lies in the fact that we now consume our stories on social media, websites, or other highly targeted forms of information that confirm our own biases.  I can no longer talk about anything political with one of my closest college friends because of this “confirmation bias”.  Sometimes I forget this and recently we were chatting about how things were back in my home State of Texas when he mentioned that immigrants were the reason for the COVID surge in the state.  I really tried not to take the bait but I asked him for his source and he mentioned a conservative website.  Instead of asking him to confirm the information with other sources of information such as the CDC or State public health website, I responded by arguing that this was just anti-immigrant rhetoric and the surge was due to the high level of unvaccinated individuals regardless of their immigration status. Needless to say, the conversation did not end well.

We are all prone to confirmation bias which makes what stories we consume so dangerous. Medicine is no exception to the impact of confirmation bias on health and wellbeing.  Ignaz Semmelweis was a Hungarian physician who noted that fewer mothers were dying of post-partum infection when they were delivered on the midwives ward compared to the ward run by the physicians.  He discovered that on the physicians ward, the trainees would perform autopsies between deliveries and then carry the infection to the deliveries.  The autopsies were not being performed on the Midwives ward.  He then ordered the students to wash their hands in a chlorinated lime solution between cases resulting in a dramatic decrease in post-partum infection and death of mothers.  The standard narrative goes that the medical establishment opposed his views as the idea of a physician causing disease was anathema to them. It continues that he wound up dying of a nervous breakdown. The reality is more nuanced.  While he did have opposition to him in Vienna partially due to his political views, he was successful in implementing his strategy in much of Hungary although widespread adoption in Europe evaded him during his lifetime. While the rejection of his evidence did lead to mental distress, he actually died of the same infection he fought all of his life which he probably got from a surgical procedure he performed.

I also have lived through an era of confirmation bias that is more nuanced in retrospect.  As a Urologic Oncologist, prostate cancer is one of the most common cancers amongst men that we treat.  Prior to the introduction of the prostate specific antigen blood test in the 1980s, men were often not diagnosed until they presented with bone metastasis and urinary retention.  At that point, there was treatment in the form of hormone manipulation but no cure.  The development of a blood test to screen for cancer, better ways to biopsy the prostate to detect cancer, and new surgical and radiation approaches to treat prostate cancer led to an explosion of prostate cancer treatment in the 1990s and 2000s.  All of a sudden we had the chance to prevent a terrible death from a disease through early detection and treatment.  In 2008, many of us who treated prostate cancer got kicked in the teeth by the United States Preventative Services Task Force, a group that makes recommendations regarding the utility of screening tools by examining the evidence available.  They gave PSA screening a grade D and recommended against routine screening for prostate cancer arguing that the harm of treatment far outweighed the benefit.  Men treated for prostate cancer were experiencing high rates of incontinence and erectile dysfunction without proof that treatment extended their life.  Most urologists were in an uproar.  How could something we do have no benefit to our patients?  Rather than weigh you down with all the details, the initial reaction was fierce but as with the other story above, the outcome was much more nuanced.  We ultimately recognized that in our effort to fight prostate cancer, we were treating everything with a hammer when some men’s cancers were merely ants that might not impact their longevity or quality of life.  We shifted our focus to identifying patients that would benefit from treatment, decreasing the morbidity of our treatments, and avoiding treatment in men with low risk disease.  I’ve simplified it here but this is only one of countless examples where we told ourselves a story in medicine and fought when facts presented to us did not match up to our view of the world.  Ultimately, the truth lay somewhere in between but confirmation bias hindered our ability to see that. 

Why is it so hard to admit that we are wrong when confronted with proof?  Confirmation bias is a piece of this but the true answer lies much deeper.  Admitting we are wrong about something requires a level of comfort and confidence in ourselves that few of us have.  Now this is extreme but the other podcast I have been listening to lately is Dr. Death.  In the first season, the presenters share the story of Christopher Duntsch, a well-trained neurosurgeon who moves to Dallas and proceeds to kill or maim 33 patients jumping from hospital to hospital.  Hospitals and medical staffs both fail to look past the training and credentials (their confirmation bias) and then pass the buck to the next hospital because they can’t admit they were that wrong about someone.  But more troublesome is that Dr. Duntsch himself failed to stop despite a rising body count that would have given most normal doctors emotional problems after 1 or 2 cases.  He chose to blame others rather than take accountability for his actions.  Of course, this is an outlier example but it does highlight the point that we often would rather protect our ego by deflecting externally than take personal responsibility and admit that we were wrong. 

The Third Season, however, highlights another reason why we have such a hard time admitting we are wrong.  Paolo Macchiarini is a thoracic surgeon who developed a tissue graft to replace diseased tracheas.  He performed at least 7 surgeries without human subjects approval resulting in death and morbidity to all of these patients.  I find this case even more stunning than the first season because our biases about how research is done led those around him to assumptions about the ethics of his surgery and research.  In turn, he could not accept blame because he functioned in a way where the rules did not apply to him because the work he was doing was so important. 

When our ideas or actions are so wrapped up in our image of who we are or our self-worth, admitting we are wrong becomes an exercise in cognitive dissonance.  How can our actions be bad when we, ourselves, are fundamentally good?  Cognitive dissonance pits our actions against who we believe we are.  The controversy over COVID vaccine mandates is a good example of how cognitive dissonance impacts both sides.  Now I want to say that I am a believer when it comes to COVID vaccination and support employer mandates for vaccination.  I don’t want to delve into a big analysis of the evidence supporting vaccination, but the evidence is all out there and publicly available to anyone who chooses to go to the CDC and FDA websites to read the nitty gritty details.  I got into several discussions with people opposed to the vaccine mandates and vaccination.  At the time, it is really hard to counter those arguments.  The really savvy people have consumed the narrative that supports their confirmation bias.  One particular person pointed to evidence in an article that suggested that COVID vaccination resulted in pre-term labor and miscarriage.  When I actually pulled that article, I found that the risk was NO different than the population level risk during the first and second trimester.  Subsequent studies have shown that COVID vaccination for pregnant and nursing mothers is safe and anecdotal evidence suggests that there is a much higher risk of ICU admission for pregnant women that get COVID and have not been vaccinated.  The key point here is that those who oppose or strongly support vaccination each selectively use evidence to confirm and support their biases. 

Now I’m not going to argue here that the truth is somewhere in the middle because I want as many people to get vaccinated as possible but I do believe there is an opportunity for all of us to heal by acknowledging that we are coming from a position of bias and for those of us who feel emotionally strong about this debate, it is hard to admit that we can be wrong about anything.  When all else fails, our cognitive dissonance on the subject forces us to point to anecdotes to support our point in a gesture of dramatic storytelling.  For those opposed to vaccination, it is the person they know that had serious side effects from the vaccine.  For those who strongly endorse vaccination (which includes me), it is the deathbed wish of the person dying from COVID that they would have had the vaccine and pleading for others to get their shot.  For those opposed, they point to the single Mom who is scared to get the vaccine but their employer has mandated the shot and they could lose their job and her kids could starve.  For those in favor, it is the outbreak in the elementary school from an unvaccinated family that has sent young kids to the Children’s Hospital.  I can go on and on with the stories we share that feed our confirmation bias and soothe our cognitive dissonance.  The problem as a physician is that many of these stories on both sides pull at my heartstrings.  Our jobs and the jobs of the nurses, health care workers, and other front line workers is all about dealing with one person at a time and our civil discourse has placed such a premium on individual liberties and rights that these two narratives feed each other where decisions made by the “other” side impact us personally. 

But arguments supporting vaccination are based on a population view of the world and not on the individual.  Public Health means public, not individual even though decisions made on the population level statistically improve the outcomes of the individual.  We don’t have debates about car seatbelts and use rates are relatively high because on a population level, seatbelts decrease traffic related mortality.  This is enforced by law and fines and for the most part, over 90% of people use a seatbelt in the car.  My daughter told me that they still show the terrible movies of people flying through the windshield who didn’t wear their seatbelt and most of the class just conceptionally didn’t understand how it was possible not to wear one in the car.  Instead of getting the other side to admit they are wrong and we are right or vice versa, we need to change the narrative on vaccination back to where it belongs.  It belongs as all vaccination and public health programs have always been on making the argument on a population level.  It’s not a sexy story to tell but it can be made compelling.  Acknowledging how people feel and then taking the discussion to visuals that make the argument for vaccination that everyone can understand engages people in the conversation without placing a value judgement on the individual.  I’m not saying it will work but it’s a way to try to take the debate beyond our confirmation bias and quieting the cognitive dissonance. 

There is one way we can grapple with being wrong.  I’m not talking about never having an opinion or taking a side.  I’m talking about the idea of healthy skepticism.  When faced with the prevailing wisdom of the “room”, your team, your organization, your family and friends, or even your community, it never hurts to consider the alternatives.  My definition may be a little different than others.  I am not talking about people who see a conspiracy theory in every corner.  There’s nothing healthy about that.  I also don’t think that it’s healthy to question every decision based on risk/reward.  Sure, we want to make sure that the risks we take are fewer than the benefits of the decision but we can’t foresee every possible outcome and skepticism that stifles innovation and opportunity is not healthy.  The two areas where skepticism is healthy in my mind are when there is an eerie lack of disagreement.  In medicine, this idea plays out in safety events.  A healthy skeptic would question the medical decision of group if the risks outweighed the benefits to the patient.  For example, when a hospital develops a new service, they cannot simply open the doors and start offering that care.  Hospital structure, process, and outcomes have to be examined and questioned to understand whether a service can safely be performed even if the individual expertise exists.  More importantly the healthy skeptic questions themselves.  When making decisions or absorbing information, they consider their biases and seek alternative information before accepting the narrative that comforts them.  They are willing to go outside their comfort zone to seek information outside their standard sources, talk to others outside of their circle, and take time to listen rather than simply react.    

At the end of the day, we all can change the narrative by trying to cut through the emotion of a story, question the lens through which we see the world, and place more value on the process than on whether we are right or wrong by examining the alternative.  I’m reminded of my kids when they were young before they were teenagers.  Now as they test their independence, it seems to be a battle of wills and winning the argument.  When they were younger, it was more inquisitive.  As I try to get my oldest daughter to go to bed before 1 AM, all I get is “Dad, leave me alone” and the air pod volume turned up despite very legitimate health reasons for sleep.  Ten years ago, it would have been a conversation.  “Why do I have to go to bed now?”. “Why do people need to sleep?”  While we can’t turn back the clock, we can channel our younger selves to be healthy skeptics, ask questions, be less concerned about who is right and who is wrong, and maybe, just maybe bring folks a little closer together even if they don’t agree.

Trapped?

I followed a very straight path to get to where I am today. I studied hard in high school to get into a good college. In college while others were having fun on a Thursday night, I would hide in the stacks and study. That helped me get into medical school where I continued my tradition. I would take notes during lecture and separate notes on the reading and by hand combine them into a single set of notes which I would copy several times to learn the material. You get the point; I strived to do well to help myself get to the next step- residency, fellowship, a faculty position and academic promotions. Don’t get me wrong- I had fun along the way and I actually take a lot of joy in learning and being better. But I have followed a very straight line of school, marriage, career, kids without any real detours and fortunately few set backs.

I think back to myself as a child. I recently pulled out photo albums from my childhood. I tried to recognize the person in the pictures and what they were thinking. Did I imagine being a doctor and having a family and living in Ann Arbor, Michigan? I always loved writing and reading. In high school, I was in speech and debate and acted in plays and musicals. I considered myself more of an artist than a scientist. My parents supported me but in the background was always the expectation of practicality and having a stable career. My parents grew up with a lot of uncertainty and they craved certainty for my brother and me.

We start our lives with unlimited possibilities. Every new person that enters the world carries innumerable possibilities. I know it’s not great to talk about Dr. Seuss now but his book, Maybe You Should Fly a Jet; Maybe You Should Be a Vet spoke to me as a kid of the world of possibilities that we as individuals could contribute to society. But these possibilities narrow as we become older. Our choices or indecision, our successes and failures, who we know, where we grew up, and so many other variables narrow our limitless possibilities to finite realities. For those with privilege like me, these realities are driven by choices but for so many others, systemic racism and bias block peoples’ path leaving fewer and fewer doors open.

I’ve recently being watching a show called Shtisel on Netflix. This Israeli series follows the lives of an Ultra Orthodox Jewish family living in Jerusalem. Like other very religious groups, their lives are dictated by very rigid rules and social expectations that direct every aspect of their day. One of the underlying themes is showing how this life traps everyone in particular roles and paths. Studying the Torah ( the Bible and other religious texts) and following the commandments are the most important achievements a man can have while marriage and children define the expectations of women. Those who try to take different paths not only risk shame and potential insecurity but also ostracism from family, friends, and the only way of life that they know.

The question before us is what takes more bravery- sticking to the path that honors commitment and expectations or taking the risk to chart our own path and risk losing security and other things we hold dear? I feel that there are distinct generational views on this subject. The “Greatest Generation” that fought in WW2 might argue that it takes strength and courage to commit to a path that was laid out by higher powers. Sacrifice, service to others, and follow-through are the hallmarks of integrity and courage. Contrast that with millennials who view following their inner voice as a road to success. The courage lies in listening to that voice.

Generations are not monoliths and as a GenX, my generation falls very much in the middle and on a broad continuum. I recently watched Dead Poet’s Society with my daughter and the arc of Neil Perry in this movie summarizes the tension between expectations and commitment and following your own dreams. His parents placed terrible pressure on him to succeed academically to go to an Ivy League University and become a doctor while his teacher, John Keating encouraged him to follow his inner voice and Seize the day ( Carpe Diem). The outcome was the tragic end to Neil’s life when doors were closed by overwhelming expectations.

I don’t want to ride the fence on my answer but the answer like many things in life is nuanced and gray. COVID has shrunken most of our worlds this past year. We have all been trapped in our homes, away from friends and family, prevented from engaging in many of the things we love. Nurses, doctors, other healthcare workers, and frontline essential workers have been burdened and trapped with the commitment of keeping services going at the expense sometimes of their own safety and wellbeing. Many have honored that commitment and that has taken courage. Many have quit because of burnout and fear demonstrating the terrible cost of this trap.

Others have flourished freed from the daily grind of commuting and spending hours in the office allowed to work from home. This freedom has allowed some to continue to work while pursuing other activities and options. For those who received payments from the Government, this financial support provided security and safety to live as well as pursue opportunities. With increasing demand in the labor market and some people who accumulated wealth during the pandemic through a combination of income and decreased spending, the media is predicting a wave of people having the courage to leave their jobs and try something new. The mobility of our society has always been viewed as an asset and the ability to take risks reaps the potential rewards of new possibilities and innovation. While the financial buffer helps some, it still takes courage to leave behind the known for the unknown. I don’t want to ignore the fact that while many people have been provided this opportunity, there are still so many others who don’t have this opportunity because of systemic racism and bias.

Neither the burnout of commitment nor the potential chaos of leaving it all behind benefit our society and the systemic bias and racism continue to harm our country in so many ways. The answer lies in being able to take a risk while being held to our commitment. There is already a model for this. Many academic institutions allow tenured faculty to take periodic sabbaticals. Sabbatical comes from the biblical Sabbath. In the Bible, G-d commanded his people to not work the fields every 7 years just like the requirement to rest on the 7th day. Many Universities and some companies especially in England offer employees the benefit to take extended paid time off to pursue other activities. Many academics spend time at other institutions or pursue activities that are innovative but are high risk. Our society values innovation and risk and broad adoption could allow people to take risks while honoring the commitments they have by ultimately returning to jobs that provided this benefit. The government could do something similar by offering sabbatical like support to people that serve in some way. This would provide opportunities for those who historically have been trapped in lives of poverty or hemmed in by bias and racism. I genuinely believe that this could help fight burnout amongst many physicians, nurses, and other professionals. Given a chance, I have many things that I would want to try that I have relegated to my bucket list. I know this sounds crazy and there are many practical things that would have to be sorted out to operationalize this but how much missed opportunity have we had in healthcare by people who have been burnt out and trapped that could have been saved to continue to care for others in the future if just given a chance to explore other possibilities?

Historically sabbaticals have only been offered to tenured faculty but the distinction in work between tenured, non-tenured, and non-academic physicians is becoming increasingly blurred. If I drill down and think about my group, I would argue that we have capacity to absorb one person taking an extended leave at a time. Most people would be willing to work a little harder if they knew they would get their turn. A greater challenge especially in medicine is the implications around quality and safety for those who have not worked in their specialty for an extended time. While most organizations have processes to return people to work through focused professional practice evaluation, there would likely need to be extra focus on people returning from sabbatical. However, I would argue that in many ways, time away could refresh individuals, build new skills, and engender innovation through the cross pollination of exploring other areas of interest. In the end, the person returning from sabbatical is refreshed and re-engaged.

I know this seems impractical but different ideas often seem difficult to implement to start. I believe we could extend the productive careers of many by offering sabbaticals more broadly. Instead of resolving ourselves to a trapped life or taking a huge risk and losing valuable effort that was spent building a career and skills, a sabbatical offers an individual to explore the greener grass on the other side while still being able to return home maybe making their home grass just as green.

Where Everybody Knows Your Name

It is the classic refrain in the surgeon’s lounge. Whenever you ask a fellow surgeon how their day is going they are either waiting to start a case or waiting on turnover. I used to remember going into a day of surgery with a sense of excitement. I was going to “heal with cold steel” ( but now mainly with the robot). And while I continue to really enjoy caring for my patients surgically, my mind is also occupied by what barriers are going to be placed in my way today that I am going to have to overcome to provide this care. Is it not having an anesthesiologist to start a case on time, a lack of adequate staffing, unfamiliar staff, equipment issues- the list can be pretty long.

My clinic can sometimes be just as frustrating. Because I practice at more than one site, the differences can be striking. In one location, I have a very consistent group of medical assistants, nurses, and clerical staff. In the other location, my nurse is my lifeline but it is rare that I know the medical assistant by name because of attrition and reassignment. I really value the idea of a team and this compounds the frustration around my care.

Like many organizations, our health system is trying to contain costs for a variety of reasons. I get it and support it. The biggest bang for your buck as an administrator is controlling staffing. Personnel is our biggest expense and not filling positions can be a way to make budget. The need for margin is crucial as academic health systems see research and other dollars drying up that needs to be reconciled on the back of the clinical mission. So decreasing staff through attrition is a easy way to decrease the cost per unit of service in administrative language.

This is often spun in a way that we are trying to reduce waste in the system. The other target tends to be supply costs. Especially in the OR, disposable costs can make the difference between case margin or not so surgeons are asked to standardize care by picking one vendor, decreasing the use of more expensive supplies, and being thoughtful about using certain items.

Again, this is a good thing- we want to decrease cost and improve our value proposition. These cost containment strategies and efforts have a natural ebb and flow. The thought is given competition, the ability to grow is not infinite given the limited supply of patients. So in order to improve margin to support our missions, we all need to chip in to cut costs. But from the ground level, I definitely don’t see a decline in patients. With the countervailing efforts to improve patient access, I see more and more patients who need my clinical and surgical care and much of the discussion in the surgeons’ lounge revolves around how busy we all are.

There are several frustrating factors about these cost containment measures. First, they are reactionary. They are a response to external pressures from board members or leadership to achieve short term goals. When the pressure is off, rather than continuing the efforts to decrease waste, things tend to back slide. If we are truly trying to improve value by containing costs, then it should be a continuous effort and not dependent on short term goals.

But more frustrating is the fact that cost containment seems to occur with broad brush strokes. Organizations tend to expect all segments to reduce costs equally rather than take a surgical approach ( no pun intended) to cutting costs. Of course, it is a much harder and politically fraught task to consider which areas can be cut more than others. We tend not to like to pick winners and losers but sometimes there are opportunities to eliminate entire programs that are not working and reinvest in areas that are either higher margin or that provide more meaning to the patients we serve. While academic health systems must provide comprehensive care, there is no shame in differentiating investing in winners and containing costs in low margin areas to help the organization succeed in its missions.

There are two big buckets of waste that often get ignored but hold tremendous opportunity to both improve value and tackle burnout amongst all those who care for patients. Recently, I was talking to one of my colleagues in the surgeons lounge. He had come from private practice and was used to being very productive. When he came here, he tried to maintain that level of productivity but soon found himself in the OR late at night to the point where his family was suffering. He was then discouraged by administration from adding on cases not because of his quality of life but because of overtime costs related to staffing later in the day. His productivity for a normal 12 hour OR day was cut by about 30%.

In my mind, that is waste. If there is a differential between what can normally be accomplished but the system creates inefficiencies causing a reduction in productivity, that is clearly waste. Add up this wasted physician time amongst all the surgeons in a health system and we are talking about millions of dollars that overshadows any other cost reduction strategy that is currently in place.

While the return on investment is huge, the roadblocks to improving efficiency within a finite time period and not overburdening the clinicians and staff is a tall order. It requires developing processes that support the work of the clinician. Administrators cringe because they immediately believe this requires the investment of more resources and while modest resource investment sometimes is necessary, the greatest opportunity is to create stable teams that understand the work and can collaborate in real time to continuously improve processes and improve efficiency.

Again, managing this is difficult. Flexible staffing models allow cross-coverage that can deal with the daily staffing issues that arise but this type of team approach does not have to be for everyone. At least in the OR, my guess is that 20% of the surgeons do 80% of the surgeries. That may be an exaggeration but it is relatively easy to determine who are the busiest 10-20 surgeons in an organization. If you could trial a true team based approach that spans the episode of care for patients even in a small fraction of these busy surgeons, then you could measure three variables to see if the reallocation of resources result in a return in investment. First, does this model increase the productivity per unit of time. This is obviously a step function since decreasing the time to accomplish a set number of cases does not decrease waste in a model where staff are paid a set salary and not by time. Second, does this model improve staff and physician satisfaction and quality of life? I will discuss this more below. Finally, does this model improve the value proposition for patients? Are outcomes better? Is patient satisfaction improved? Is cost stable to improved because the team does not use extra supplies because they are knowledgeable of the care being delivered?

The second area of waste that also intersects with the second metric above is staff turnover. Some data suggests that turnover rates in hospitals are approximately 20% per year with the average cost averaged out amongst all staffing categories of $60,000 per lost employee. That is a staggering number if you consider a larger health system and a real area of opportunity.

Now people leave for a variety of reasons- career advancement, to be closer to home, family reasons, dissatisfaction, benefits, hours and the list goes on and on. I have been frustrated over the years by HR practices that prevent me from helping to retain good employees. While a discussion of reducing turnover is beyond my expertise, I do believe that creating stable cohesive teams can both improve efficiency and satisfaction amongst everyone on the team helping health systems reduce cost and improve value.

If given the opportunity, I would take another approach to containing cost that values time and people. Stability of staff beats saving money through attrition. Waste in the OR often occurs when unfamiliar teams are working together. Sure SOPs can be useful, but they don’t beat a team that knows exactly what is and is not needed for a surgery. They can also continuously improve both outcomes and reduce waste that can’t be done by a static process by inconsistent teams. I would trial this approach with a few surgeons or busy clinicians and empower people locally to make decisions that support better patient care and efficiency rather than some centralized process developed by those who do not know the work. Money spent on more oversight, project managers, outside consultants, and expansion of administrative overhead could be reallocated to those caring for patients. Metrics like those above can provide accountability coupled with PDCA cycles to improve on care delivered rather than resourcing the squeakiest wheels in the organization.

These efforts would go a long way to improving both costs and satisfaction amongst every employee grouping who cares for patients. In the immortal lyrics of the 80s sitcom Cheers, ” Sometimes you want to go where everybody knows your name; And there always glad you came; You wanna be where you can see; Troubles are all the same; You wanna be where everybody knows your name.”

Thanks for reading.