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Unexplained variation in how we practice medicine is more dangerous than you know.

Dr. Bill Rifkin, an internist, hospitalist, former residency director and managing editor of MCG Health joins me for a shockingly frank discussion about how we cause harm through variability in our care, and how we can do better. Topics discussed include: cookbook medicine vs. autonomy, the role of nurses in witnessing unexplained care variability and dangerous practices, the role and limitations of clinical guidelines, fear of malpractice as a driver for excessive interventions, doing paps on 75 year women with severe illnesses, optimizing Health 2.0 so we can reach Health 3.0, could doctors be more like pilots, how to influence behavior change, and antivaxxers/vaccine science. Learn more about Dr. Rifkin’s work here.

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– We’re live! Hey, Z-Pac, I have a special guest today. We’re really excited, ’cause we’re gonna talk about how we can kill less people, harm less people, and actually look deep inside and see what we’re doing in a way that we are unable to do now as clinicians.

– [Bill] Yes.

– Nurses and everybody, they already know kinda the care variation in this country, how some doctors are better than others. But the thing, you know who doesn’t know that, are doctors. And I have with us today Dr. Bill Rifkin. He is the, he’s an internist, used to be a Program Director at Albert Einstein, is the Managing Editor at MCG Health. And he’s here to talk about this stuff. Bill, welcome.

– Thank you, pleasure to be here.

– It’s interesting, so we’d connected on a phone call, and I wanted, I expected to hate you. I’m gonna be honest. Because in this show–

– [Bill] I get that a lot.

– Yeah, it’s something about you, man. No, no, no. It’s because you’re talking about guidelines, about measuring variation in care, about what I like to call the measurement industrial complex, which we’ve been clicked and measured and cook booked into cookbook medicine.

– [Bill] Yeah, absolutely.

– And so it triggers a lot of frontline docs to go, “Wait a minute, no, I don’t want this in my life.”

– [Bill] Right, right.

– “I need autonomy.” But when we talked, I increasingly found myself cheering and rooting for what you were doing, because you have nailed it, which is we don’t know what we don’t know when it comes to care variation, how somebody in Texas practices completely different medicine than somebody in New York. But yet, we actually have data as to what the right medicine is.

– [Bill] Right.

– So, you know, tell us where to think about this, even, to begin with.

– Yeah, so I often am put before docs who are, they start off, I might have like two strikes against me already, ’cause you know, you’re coming from this guideline place, and you’re gonna tell us we’re doing something wrong.

– [Host] Yeah.

– You know, so it’s not a very good conversation.

– [Host] Triggered.

– Triggered right off the bat. Usually when they actually either see what’s in the guidelines, or what the data is, they are much less threatened, ’cause it’s clinically reasonable, and it’s not black and white and cut and dry. There is very little in medicine that is like absolute, like this number means you need to be admitted, this number means you don’t need to be admitted. And it’s a very difficult situation the doctors are in, because they have to justify their decisions for a payment mechanism, which requires them to do more documentation than they had ever done before, and to basically show their math a little bit.

– [Host] Yeah.

– What made you say the CHF patient needed to be admitted? Not just, you know, pulmonary edema, diarrhea, admit. And then there’s been this added new thing of observation care, which you know, we were all trained it was admit, don’t admit.

– [Host] Yeah.

– And now it’s admit, don’t admit, or try to put them in observation care, which might end up as an admission or not. So rightfully the docs are either confused, or have heard the wrong thing, and they need some guidance, but it’s also like a frameshift. A lot of the situations that were slam dunk admissions, you know, when they trained, so CHF comes in with enough pulmonary edema to be hypoxic.

– [Host] Right.

– Used to be, “Oh, that’s an admission.” Easy.

– [Host] Right, right. You know, let me call the residents, an easy admission. Now, not necessarily. It depends how they respond to initial treatment.

– Well so, and again, I find myself being drawn into this conversation, because as a hospitalist, you are a hospitalist as well, as the measurement industrial complex started interfering with our autonomy, and that’s how we felt about it, they were telling us, “Okay, no, this is definitely an obs, “and you screwed this up, and now “the hospital doesn’t get paid, and it’s on you.”

– [Bill] Right.

– Or, you clicked the wrong boxes to show that this CHFer needed to be admitted. But in the background what’s happening is our entire care paradigm is changing. We no longer have to admit a pulmonary embolism, if we can get them outpatient anticoagulation, and they’re stable, and they. But, so many doctors are still practicing either back here, and we don’t have mechanisms to even compare ourselves to other physicians.

– Right. Actually, PE’s a great example.

– [Host] Yeah.

– The study’s a little bit old by now, but there’s this great graph of what percentage of PE patients coming to, you know, one of 500 EDs is treated as an outpatient? And the curve is like this. So there’s, you know, maybe an eighth of the EDs that read the study, and it’s like 15 percent, maybe it’s even too high. And then there’s a third of the hospitals the number is zero. They never heard of it, they never considered outpatient treatment. And probably all the docs in that hospital are practicing similarly, and all think they’re doing the right thing.

– And that’s the thing, we don’t know what we don’t know. And people are like, “Trust your doctor, “they know what they’re doing.” Oh my God. Bill, I’ve looked at your data of care variation across the country.

– [Bill] Yeah, it’s terrifying.

– It is terrifying. The number, okay, just take a bariatric surgery. So, surgery to lose weight. If you look at the best surgeons in terms of outcomes, quality, et cetera, they’re following guidelines, they’re at a center for excellence. Compare it to somebody in the community that’s doing bariatric surgery. The difference is that person in the community needs to treat 11 people to have one extra person die from a complication.

– Yeah. I mean, some of the real shame of this is also why isn’t this more common? So, there is this great study with bariatric surgeons where they actually did, all the surgeons in Washington state made a tape of them doing the surgery, lap sleeve.

– So they videotaped them doing the surgery, yeah.

– They actually videotaped them doing it, or the key part of it. And they sent these tapes to other surgeons who were trained, and their ratings were similar to each other, and they rated the people on a curve of skill, actual surgical skill.

– [Host] Who was rating them now?

– Other surgeons.

– Other surgeons, so just a mix of surgeons.

– Yeah, but a group that was trained to evaluate, and it’s, you know, if I said it was good, he’s likely to say it’s good.

– [Host] I see, so they’re a little higher level on terms of the–

– And their ratings correlated with complications. So, it was very interesting that there was even a study like this, and yet this is very rare. This is notable, because this study exists, it’s very rare.

– So, so, so, let me just rephrase this ’cause I think this is the most important thing that we can say today. There is data that shows that an independent panel of surgeons can review different surgeons’ procedures and what they determine, “Oh that was appropriate, “that was not appropriate, that was good, that was not bad,” that correlates directly with the number of complications that surgeon has.

– [Bill] Yeah.

– In other words, we have a known and proven mechanism for evaluating surgical technique, yet these surgeons vary in their abilities, are allowed to vary in their abilities, and patients have no effing clue which surgeons are better than others.

– Right, and it’s not just surgeons, I mean surgeons are always, always pick on surgeons–

– No, no, I like to pick on surgeons because they like to consult us as hospitalists, yeah.

– Yeah, they always make fun of us.

– [Host] So we have to go back.

– Anytime we can do, they actually do something, we just round and talk–

– I’m actually quite jealous of them. ‘Cause they do stuff, still heals.

– Right, we’re still rounding, and they’re like over here–

– [Host] I know, we’re still rounding talking about gout.

– Right.

– And they’re actually removing somebody’s spleen.

– “Do you know the Romans?” “Yes I know, they had gout.” But so it’s also true in internal, internists as well. I guess the basic thing is, most patients are not in a position to evaluate if their physician is good or not.

– [Host] Right.

– They judge them on their manner. I actually even saw in training that the docs who were well thought of, and were like the leaders, weren’t always the best clinicians. They were nice to their patients, they basically did what their patients wanted them to do so they were popular, they were popular in the hospital because they were doing things that brought in a lot of money, but like, we all knew they weren’t the real best clinicians, and I guess, once you’re done with training, docs very rarely are actually evaluated on what they do or their outcomes or their decisions. Like you know, do you admit more patients than I do, and why?

– Yeah, yeah, in a meaningful way. So we have maintenance of certification, but that’s just a bunch of questions on a test that don’t correlate to what I do as a clinician.

– [Bill] Right, you have to do this right.

– Yeah.

– Because, you’ve probably lost a few generations already where you know you’re either measuring them by a bad measure, like I think readmissions is a bad measure.

– [Host] Right, ’cause you don’t know–

– ‘Cause you’re measuring them for something that’s not in their control. Or it’s bad data. You’re blaming them for patients, “That wasn’t my patient. “Yeah, I admitted them, but I wasn’t the one “on day three to make the decision.”

– [Host] Right.

– Or you’re just doing a whole group, we’ll evaluate the hospital as a group, but then everybody says, “Well it’s not me, it’s him.”

– See, and then we feel powerless, we feel like we’re being graded on things that are beyond our control, like you said. We feel like we’re being told to practice cookbook medicine when in fact there is nuance. So, but the thing is, there is a way to do this. And so, you know, you work with this group that creates some guidelines, some technology that helps us, but you get a lot of pushback from docs, right, so if you implement at a hospital they get very upset?

– Yeah, often, I don’t even know what percentage it is, but one of the roles I have is you know, the, since we brought our guidelines and they’re rolling it out and they —

– [Host] Boo!

– Case Managers are using it, and then some of the docs are like, what is this, you know, somebody says MCG gives you two days length of stay. Like, who’s MCG, and why two days?

– [Host] Right.

– So then I walk in and say, “Hi, I’m from MCG.” And I’ve actually been like cornered in the physicians’ lounge, you know, by two pulmonologists, and their posse behind them. Saying, “Are you the guy who says all PEs are four days?” And I’m like, “Me, no, we don’t say that at all!” You know, so it’s misinformation, the whole concept of a goal length of stay is some of the time it can be four days, and there’s reasons it can be more that are perfectly rational, and then there’s reasons that we all know are not rational, and you know, or systems issues, and differentiating between the two is how a hospital can improve, but the first thing was almost like daring to measure their length of stay ’cause every, the first things doctors say is not my patient, and the second thing they often say is, “But my patients are sicker.” So you have to prove with your data that the patients you’re looking at are very similar to their patients.

– Right, risk adjusted data.

– Right.

– Is important because that’s a thing that surgeons will say. “You’re reporting my complication rates, “you’re making this all public, I’m looking terrible “because I’m the only person who takes these sick patients.” But you, can you adjust for that?

– So, there’s lot of studies that have formally adjusted for it and still find these differences.

– [Host] Right.

– We can do some of that, and also some of it is, we look at so many patients, so we look at so many heart failure patients when we say the admission rate is, you know, 70% for Medicaid, Medicare CHF patients. We say that based on literally hundreds of thousands of patients, so when somebody comes to me and says, “Well, my patients are, CHF are old,” I’ll say, “Well, actually half of our cohort “is over the age of 75, and they have diabetes, “and they have kidney disease,” So our patients look like your patients certainly in broad strokes to come up with reasonable targets and to show this data to people and say this might be valid.

– Well so, what’s interesting to me is I think, and there’s a little pushback I’ll push back on because what you’re saying is absolutely true, we can do so much better. The nurses know that there’s variation in care and it’s not good.

– [Bill] Yeah.

– They know the one doctor who does things well, and the one doctor who doesn’t do things so great, and one doctor who they would not send their dog to.

– [Bill] Right.

– They know this, but this is not public data. Now, where I think where physicians are feeling beleaguered now and where it’s hard is that, say a company like yours comes in and says, okay, we have this way to improve it, but you don’t motivate the heart. In other words, there was this guy, you’ve probably heard this story, Ignaz Semmelweis, he was a doctor in the 1800s, and we had the vitamin C sepsis guy on the show, Marik, talking about this. He found that, wow, he did a study if you, the nurse–

– [Bill] If you wash your hands.

– If you wash your hands on an OB ward, the women don’t die of puerperal sepsis.

– You’d think they’d want to wash them anyway, but yeah.

– You would think, but back then they didn’t know, the germ theory wasn’t a thing.

– [Bill] Right, right.

– So, so, the midwives were having these great outcomes, and the doctors were not. So what happened when he publishes this stuff? They fire him. He dies in a mental institution. Why, because doctors, no one approached their elephant, their unconscious limbic system. They were defensive, they’re like, “We can’t be causing this harm. “We’re already beleaguered, “they’re making us do all this stuff. “How can the nurses be doing better than us?”

– [Bill] Right.

– And so we have to get, when I talked to you on the phone, one thing that got me was, you made me feel something that, wow, we need to do better for our patients and for each other in terms of eliminating care variation because we’re hurting people. My mother, my father, if they go to the hospital, I want them to get the same good care.

– [Bill] Right, right.

– Across the system, and we’re not doing it.

– It actually has to come from, first of all, you know, some doctors I’ve worked with are my heroes. So, you know, it’s sort of like the soul is good, it’s, it would be akin to a pilot on the East Coast, they fly a certain way, and the pilot on the West Coast flies a different way, and in a given situation, let’s say there’s a right answer, you know, there’s not always a right answer in medicine, but if there’s a right answer, you would hope that as a profession we would have, well, most people are gonna pick the right answer, and if you’re not picking the right answer, somehow that would get noted and fixed. You know, we inspect pools, we inspect elevators, how come we’re not nothing that these things are happening, ’cause you’re absolutely right, the nurses know. Remember like when you picked up somebody’s service, you picked up another physician’s service, some of them were huge because they never discharged a patient.

– [Host] Yeah, the rock garden.

– Right, and some of them were very small because they did, and everybody felt, “Well my patients were different that month.” Month after month, their patients were somehow different than everybody else’s patients, and hopefully with the right data and the right approach, and certainly appealing to their, almost every doctor I’ve met wants to do the right thing, you know.

– [Host] Yeah, yeah.

– And it’s just, it’s sort of getting past the threat and it’s not like “I gotcha” type of mistakes, it’s more just, you know, “Gee, in your ED, “a patient is literally twice as likely “to be admitted than an ED over here.” Maybe there’s some differences in the patients, but not enough to explain all that. And that’s been shown in study after study after study.

– It’s never enough, the differences are never enough to explain it, it’s the practice patterns. And we all know this because if I pick up a service from Bill versus John versus Nancy, I know in advance what their patterns are like.

– [Bill] Yeah.

– I know Bill’s gonna be a rock garden full of over-testing and over-intervening, I know Nancy’s gonna be somewhere in between, and John’s gonna discharge them all early and they’re gonna bounce back.

– [Bill] Right, right.

– By the way these names are not made up, but the practice patterns are. And so the question is, you made the analogy of the airline pilots, you know, you wouldn’t want so much autonomy in your airline pilot that they’re able to do barrel rolls.

– [Bill] Right.

– But you want enough autonomy that you have a Chesley Sullenberger who when the cookbook, flying–

– We’re off the reservation, right.

– They were off the reservation, he has enough autonomy, critical thinking, and skills to go, “I’m gonna land this ish in the Hudson “because I know, I feel this plane, “it is not gonna make it to the airport–”

– [Bill] They can’t get back.

– “To the airport they’re trying “to get me to go to, to Newark.” So you need that, you need it in nursing. In nursing right now, they’re just told click the boxes and call the doctor.

– [Bill] Right.

– They used to think critically. And the older nurses are, they’re burning out, they’re being forced to retire, replaced with these, the new nurses that are just like click, click, click, click, click, call the doctor, document, no thinking. So there’s some gray area with cookbook algorithms and autonomy that we need to find.

– Right, absolutely, I mean, good guidelines are flexible. You know, if some guideline, what I like to say is like you know, I can’t tell you how many ribs up the pulmonary edema has to be to admit a CHF patient.

– [Host] Right.

– I could make up a number, but you can’t beat evidence-based, clinically real, and precise beyond the evidence. So you’re gonna use words like severe, persistent, what does that mean? Well, describe it in your note, you know, did they respond to treatment? So, it’s not removing autonomy, on the other hand, it shouldn’t just be a blank canvas.

– [Host] Yeah.

– A doctor shouldn’t be able to do the wrong thing so easily. I mean there’s studies that are truly frightening. One that stands out to me is where they’re measuring what patients got screening tests at what age. So, you know, a PSA for prostate cancer or a Pap test for cervical cancer. The study looking at patients over the age of 65, and based on survey results they can put them into like high risk mortality over the next five, nine years versus low risk, and the difference in the screening wasn’t very much, and people were still screening these very, you know, a 75-year-old who’s really, really sick, they’re still doing a Pap test or a PSA on them, it either means it’s just completely rote–

– Yeah, you’re just clicking boxes, right.

– Or they’re being measured by it somewhere and they just feel like they can’t explain why they’re not doing it, so they’ll just do it, or they don’t know the math, and their understanding of a screening test and benefit in 10 years doesn’t make sense for this patient.

– It’s crazy!

– Yeah.

– And if you really look at it, and see this is the thing, I’ve seen your slides of your data, I didn’t put them on the show because I don’t want to trigger a mass riot in this country.

– [Bill] Right, right.

– But if they saw the clinical care variation data on how much it’s harming our patients, these aren’t our patients, these are our loved ones, these are our brothers and sisters, and our parents, and our children that are being harmed. We never, you know, you and I are docs, we’re at hospitals, so we can build a wall around ourselves and not feel stuff, we’re good at that. When you feel it, you just get upset.

– [Bill] Yeah.

– And you know Jill, Jill Gambon says here, I think the word you’re looking for is getting past their egos. Do you think ego is a thing, or do you think it’s, we’re just conditioned? What do you think it is?

– Well, part of it I think is ego, ’cause for example, there are situations where they want me to go talk to the people, not–

– [Host] Because you’re a doctor.

– ‘Cause I’m a doctor.

– Right, deploy the Rifkin.

– Right.

– Right, exactly.

– Some of it is also because I’m an obnoxious New Yorker, and you know, if somebody corners me to talk about PE, I’ll push back.

– [Host] Yeah, yeah, yeah, I love it.

– But, so some of it is just that culture thing, but some of it is, you know, it’s a good thing that docs have confidence. You want your doc to have confidence. I think it goes too far if they are defensive and resistant.

– [Host] Yeah, yeah.

– So if somebody comes up to them with valid data that says they’re acting, or their decisions are somehow at variance, significant variance over time, from some other benchmark that we think is reasonable, that oughtn’t be threatening as much as, “Gee, I better read about it, or hear more about it.”

– Ah, it oughtn’t be, but I’ll tell you, humans work.

– [Bill] Yeah, yeah.

– You know, I mean, on this show we’re very much about how do you persuade other people to do the right thing, and a frontal attack using data, when their belief is something different, will fail every time unless you first form commonality, get an emotional connection.

– [Bill] Right.

– Maybe use a little humor as a Trojan Horse, and that’s why I like you, Bill, because when we got on the call, you know, it’s like here we are, two doctors, we speak the same language, we don’t take crap from anybody, we don’t like administrators any more than anybody else.

– [Bill] Right.

– But yet at the same time, in our hearts we want to do the right thing for patients.

– [Bill] Absolutely, absolutely.

– So, motivating people then you can use the data and go, look Z, I bet you didn’t know. And that’s what you did with me.

– Absolutely, absolutely.

– Yeah.

– ‘Cause also some of it, frankly day in, day out, the way it’s being presented to doctors is brutal, it’s like denial, so meaning somebody six months later, looking at your chart, says, “I don’t think they need to be in the hospital.” And sometimes their reasons are right, sometimes their reasons are wrong, but you get, you’re already in that contentious, you know, you have to defend what you did.

– [Host] Oh, and it’s very unpleasant.

– [Bill] It’s very unpleasant.

– It feels like you’re being attacked directly, yeah.

– Right, right. I mean, I guess the unfortunate reality though is that the only reliable break in our healthcare system are the payers, I mean, so it’s not the big bad payers. I mean, nobody else is saying, “Gee, maybe you don’t need that,” total hip, total knee, whatever surgery it is. So, unfortunately, the system we’ve fallen into is, you know, often the doctors are, rightly or wrongly, on board with a pathway, you know. This is what they do for a living, or if it’s a gray, it’s a close call, they’re gonna err, you know, incentives work.

– [Host] Yeah.

– I don’t think it’s a secret. So, we’ve developed a system where the yes and no is coming from the payers, not from the doctor, patients talking to each other or at least some of the time the doctors saying, “I don’t think this is the right thing to do for you.”

– Right. Well you know, you see, okay, this is a piece that I think is fascinating. The payers, insurance companies, are the only actual people here whose financial incentives actually align with doing the correct amount of care.

– [Bill] Yeah.

– Now they don’t always get it right, and so their prior auths are onerous and we hate them and they deny stuff based on bureaucracy, but when it’s done correctly, they’re the only people going, “You know what, all the data says “what you’re doing is at variance.”

– [Bill] Right, right.

– And we hate that because we hate insurance companies, right? And patients hate it because–

– [Bill] It’s instinctive, yeah.

– You’re taking the doctor/patient relationship and you’re interfering with it. Could it be that we could actually transcend that by not making it a payer, and I know you have to do it now, but could it be that we could actually just have clinicians doing the right thing because it’s the right thing to do? You know, if they have the tools–

– Right, if they have the information at their fingertips, if, if, if–

– [Host] Point of care.

– If they really knew, like let’s say this doctor who’s ordering a PSA on a very sick 75-year-old man.

– [Host] Right.

– If somewhere in the process they knew that this was an odd decision or something, would that help? There’s even a study about that where they took patients who had either acute coronary syndromes or PE and sent them vague symptoms that could be one of those in an ED, so they–

– [Host] Right, chest pain, shortness of breath.

– And they randomized, one set of doctors was, in their EMR, they had a web tool that, based on a Wells’ Criteria or TIMI Score, told you, gee, this patient is low risk for this, if you do a troponin, or you do a D-dimer, you can discharge him.

– [Host] Right.

– So, and then half the docs didn’t have that tool.

– [Host] Right.

– The docs, the physicians consistently overestimated the risk. So like the tool said 76% of the patients, if you do this blood test, they can go home. The doctors said 30% of the patients are in that category and they overestimated the risk so that they then had to get further testing, further testing. To me that seems like a factual, like it should be relatively less threatening. The factual, this patient’s chance of a PE is lower than you think it is.

– Okay, let me give you the counter argument that the docs will give. “But if I get sued because this was one “of those one in 1,000 where we miss it, “can I rely on these guidelines then to defend me?”

– [Bill] Absolutely.

– “And if the answer is no then I’m gonna over-test.” Yeah.

– Absolutely. So, I always, I think the first thing is that a lot of the, a lot of the problems the doctors report are accurate. I mean, you know, in my position, I’m in a very unique position, I hear horror stories from the payers, I hear horror stories from the providers.

– I’ve been in that position too, yeah.

– And they both have their–

– [Host] Valid points.

– They have their points, right? I think, I never know what to do with the defensive medicine thing, ’cause on the one hand, it’s true. I mean, you hear the horror stories of somebody who documented a conversation about the PSA, they followed six guidelines and they did all this and the guy sued him 10 years later because he got prostate cancer and was successful.

– [Host] Right.

– I don’t know if that’s the tip of the iceberg, and lots of people are in that, or that was one case out of 10,000. Usually, what my response is, you know, try to do the right thing for the right patient, and ordering extra tests, sometimes it might make you feel safer, sometimes it could be worse. You order that CT angiogram that wasn’t necessary and it shows a small pulmonary nodule that you didn’t react to. And that becomes a problem in 10 years.

– Yeah, yeah. Or you’re injecting dye and you box their kidneys.

– [Bill] Right.

– Or, actually you know, and this to me is the fundamental nuance in this that I think we have to get better at. There is the malpractice, there is the litigious stuff, but there is also, there’s who’s gonna own the responsibility for it. So when these new PE guidelines came out, I was, as a hospitalist, I was ecstatic, because I hated admitting, you know–

– Just for heparin and Coumadin.

– Heparin and Coumadin. It’s like this person doesn’t want to be here.

– [Bill] Right.

– They don’t need to be here. And so, this is what would happen, I was telling the ER at Stanford, look guys, there’s the perfect example of somebody you can send home with the thing and you know, and have him follow up in our clinic, outpatient, ’cause we’re all integrated. We’ll see him tomorrow, we’ll get the INR, we’ll make sure, and they are high functioning, they can inject heparin BID, it’s perfect. And the ER doc would say, “I’m not getting sued doing that.”

– [Bill] Right.

– Like, “You come down here, and you discharge the patient.”

– [Bill] Right, yeah.

– And you know what, I did.

– I’m smiling ’cause I did the same thing. I’d bring my little posse of residents down, and I was angry, and you know, I would do it, and then I’m like, I hope that was the right thing to do. It felt very good.

– It felt really good, but then–

– [Bill] It felt really good.

– Back of your mind, you’re like, you know what, are these guidelines really that good, how many people did they study, I’ve looked at the primary data, but maybe I’m just not smart enough to see the holes in it. Maybe this ER doc who’s 10 years my senior–

– [Bill] Has something, knows something, right.

– Has something, knows something.

– He’s picking up a signal or something, yeah.

– He’s smelling something in this patient. But more often than not, it’s not. It’s just practice patterns, it’s ego, it’s fear.

– Right, I mean, patients are, you know, patients and doctors, they both, I mean, you hear about the cases that go very wrong, so doctors getting sued even though they did the right thing.

– [Host] Right.

– Studies are mixed on how much defensive medicine actually does contribute to the care, you know.

– That’s right, they are mixed. Some people say 10%, some people say it’s not that, yeah.

– Right, but it certainly sounds logical. Another variable though are the patients themselves. So, in the New York area, for example, you try telling somebody with a backache that’s not better in three days that they don’t need an MRI.

– [Host] Yeah, oh yeah.

– Or for their kid’s headache–

– The demands.

– They don’t need a head CT.

– [Host] Demands of the patients, yeah.

– It also becomes like a self-fulfilling prophecy. So patients in high utilization areas are used to certain levels of care.

– [Host] Right.

– Well, this is what happened last time or the other doctor did it. But somebody has to start changing it. That’s how we get these islands of variation because they do do it differently over here but the patients are used to that.

– Yeah, you know that’s a key thing, patient expectation, and again, I mean if I look through these comments, by the way, these comments are great. They’re really appreciating this conversation we’re having because it’s a conversation that a lot of people–

– Is it mostly my family?

– It’s all your family. They’re all last name is Rifkin, what’s the deal with that? I think that, see monitor and treat the patient, not the monitor, treat the patient, not the numbers, and again, this has more to do with you’re, this is what I like to think of it as, you’re evidence-informed, guideline-informed, but not evidence-enslaved.

– [Bill] Right.

– You’re not telling Sullenberger, “You cannot land in the Hudson,” you’re saying–

– [Bill] It’s off the guidelines, right.

– It’s off the guidelines, you use your judgment. This is where all your 10,000 hours of training, and you know, I saw, I tell the story, Sullenberger, Chesley Sullenberger, I saw, he opened for me at a Kaiser Conference Mid Atlantic.

– Wow.

– So I had to follow this guy.

– Follow that!

– Yeah, and you know who went first?

– So, he saved 500 lives like the other day, and you’re like, “Well, I–”

– I’m like, “I’m a clown on YouTube.” It was literally like that. So he goes up and he does this thing and he plays the tapes from the day, the FAA tapes, that aren’t public, and you’re sitting there just everyone, all, there were 1,000 physicians in the audience, they’re all Kaiser docs, and they’re listening just riveted.

– [Bill] Right.

– To this, ’cause they’re putting themselves in that plane.

– [Bill] A situation like that, yeah.

– A situation like that. And he’s like, this is what happened, you know, the birds hit the, the minute they hit the engines, you could smell in the cockpit the burning birds and you feel, he says you feel it. It’s not, nothing on the dials is changing.

– [Bill] Like a stall.

– But you feel the bottom drop out, and he’s like, it’s the worst feeling, and for 30 seconds, you’re just paralyzed, you’re just incapacitated. Then everything you ever studied for, every flight he flew in the Air Force, everything, all kicked in.

– [Bill] Kicks in.

– And the team, he has his copilots, he has his stewardesses, the airline.

– [Bill] Eeverybody knows what to do.

– Everyone knows what to do.

– Yeah.

– And they all go into overdrive.

– [Bill] Right.

– Here’s where we violate the guidelines, here’s where we do the checklist.

– [Bill] Right, right.

– And he lands the plane in the Hudson, and they play that, and he says at the end, he says, you know, “And so I want you to think about “those 32 seconds on which your whole life is judged, “and are you ready for it?” And when I think about what you’re doing with care variation, this is how we should think about it, this emotional, intuitive truth that we can do so much better with a little technology, a little science, and a lot of heart and caring.

– [Bill] Absolutely.

– And less ego.

– Yeah.

– And everybody was crying in the audience, and then I have to go up, hey guys!

– [Bill] Hi! It’s also important, good guidelines also know that not every situation is about a guideline, has a guideline.

– [Host] Yeah.

– You know, so yes, some patients with heart failure, pneumonia, COPD, but there’s going to be exceptions. So, nothing, I can imagine nothing would be more demoralizing than you know, a team does some great work on a COPDer, they’re intubated, then they extubate them, they make them all better, and then somebody comes by later and says, “That was wrong, it was off the guideline.” I mean, that would be, you know, so guidelines could be misapplied, they could be overly ambitious in what they cover. But on the other hand, there is best practice, there is science, there is data about what to do. One of the ways I put it is, I show some slides about variation, you know, and I say, slides like this, you’re the CMS administrator, so you have billions of dollars and you’re spending it and you see these curves of different care, different places, you’re like, why is that happening? You know, isn’t it the same disease in different places? And, you know, that type of variation I think makes it harder for doctors to say, like “I’m the doc, leave me alone. “I know what I’m doing, I’m the doctor, leave me alone.” You know, that’s the basic answer we have, and unfortunately, when you do that, you get this variation.

– Yeah, so we need to let go of some of this 1.0 thinking. Now the pushback will be, “Well you guys are just health 2.0, “you’re the matrix and commodifying us.” No, the way I think about this, and talking to you inspires me to think about this more, you have to optimize the ship of 2.0 so we get to the shore of 3.0 where we’re able to spend time, re-personalize the relationship, true precision and unique person medicine means you know the guidelines and when to violate them.

– Absolutely. Or guidelines have a recommendation.

– [Host] Right.

– They’re rarely mandates.

– Cut and dry.

– Right. That’s actually a plus and a minus. So, in our content for example, there are times where the evidence lets us say something like, this FEV1 number after this number treatments means you should admit this asthma patient.

– [Host] Yeah.

– You know, there’s evidence-based guidelines out there that we can cite. So you put a number out there. So then, people will be like, “Well, so one above means admit, “one below means don’t admit?” It’s like, well, no.

– [Host] Come on, yeah.

– You know, so precision can work both ways.

– Yeah, no, absolutely. And the other thing that you said that I want to bring us back to is, there are a lot of things in medicine where there is no answer.

– [Bill] Yes, yes.

– We don’t have a guideline, we don’t even have a clue.

– [Bill] Right.

– And that’s the sacred space where you and me talking in a room, you’re a patient, I’m a doctor, or vice versa, that’s where we thrive, and we can get to that spot by taking care of the stuff we know we have guidelines for correctly, so that our mothers and our fathers and our sisters and our children are getting the same care no matter which hospital they go to. The other think I think is we need more centers of excellence and less just random community hospitals everywhere.

– Yeah, the data is very consistent that you know, for high tech things, certain places, if you do it a lot, you get better at it, you know.

– [Host] Always, yeah.

– Than dabbling in it. I think, like PCI, in terms of humility, so doing percutaneous coronary intervention for stable, not ACS, for stable disease–

– Stable, ab, chest pain, angina, putting in a stent.

– So you know, nothing can make more sense than I do a cath, I see a blockage, I’m going to open it. That is plumbing, it makes sense, it must work, right?

– [Host] Right, right.

– Well, maybe not. We assumed it always works, it makes so much sense that, it made so much sense we couldn’t even study it in this country.

– [Host] Yeah, ’cause it was–

– You couldn’t find cardiologists to randomize somebody to not get a stent, so they did an amazing study where they actually did, in Britain, I guess you can tell them what to do.

– [Host] Communists, right.

– A little bit more, right? So they randomized patients to get a cath and a stent for their stable angina, and another group got a cath, only the lab people knew who got the stent or didn’t, the follow up doctors couldn’t tell who got what, and they tested them on stress tests–

– So it’s like a sham cath.

– A sham cath.

– Yeah.

– And they tested them on objective measures, subjective measures, and there was no difference between stent and no stent. For a stable angina, one vessel disease, failed medical management, and it was like?

– And here’s the thing, that stent causes problems in itself, you can have restenosis, you can have problems.

– [Bill] You have to take double–

– It costs a ton of money.

– You have to take double–

– You have to take double the anticoagulants.

– Yeah.

– Plavix.

– Yeah.

– You cannot overstate this over-treatment problem in the US and doctors get very triggered by this. Why, because our incentives are to do things to people in our current system. We get paid for it, we were trained to do it, it makes sense, you’re right, the plumbing, all makes sense. But the truth is, like you look at knee surgery, if you look at spine surgeries, you look at, most of the time a sham surgery is the same. Shame acupuncture is the same as regular acupuncture.

– [Bill] Yeah, yeah.

– What’s going on, it’s called the mind/body, people care about me, they’re laying hands on me, they’re doing something.

– Right, if taking a sugar pill could convince your mind that something good is happening, imagine surgery.

– [Host] Oh, it’s 12X.

– I’m recovering from, look at the scar, I’m recovering, I can barely walk for a week, this must have been something good for me.

– [Host] Yeah.

– And the irony is, the FDA has a process for medicines to prove that they work. There isn’t that for procedures.

– [Host] No.

– And so there was an editorial with that study that said, you know, this should change everything. Not every cardiologist agrees that that study should change everything, but they sort of made the case of, if it strikes you as perhaps unethical to randomize like sham surgery, well isn’t it even more unethical to have this procedure done millions and millions of times for years and years and years that may or may not be beneficial? I mean, that’s, so you know, a quicker way to get an answer would be the greater good.

-One thing I like to tell my patients when I first admit them, you are now in the most dangerous place on earth. My job is to keep you safe and get you home safely and quickly and make sure we treat your problem. I’m gonna be your ally in this. If you notice anything off, if you have questions, if you think something’s not right, you need to tell us right away or you need to have a family member or a friend here to watch your back, because it is hard, it’s a complicated place.

– [Bill] Absolutely.

– And this gets to the heart of, we’re doing things to people instead of necessarily for them, and if we can figure out that PCI for stable angina, one vessel disease, doesn’t help, we should stop fricking doing it.

– [Bill] Right, right.

– And it’s gonna mean reconditioning a ton of cardiologists, particularly in the community. Sandeep Jauhar wrote a great book called Doctored: the Disillusionment of the American Physician. He’s a Long Island cardiologist academic. His brother is a, outpatient cardiologist, private practice. Their practices could not be more different.

– [Bill] Right.

– And across the street from each other, and the idea he, in the book he talks about just constantly cathing people for GERD, doing treadmill stress echoes that are totally unnecessary, finding a little something on that, and then pursuing it. It’s our incentives, as Robbie Pearl was on our show from Kaiser, and he said context determines behavior. And our context in this country is totally screwed up.

– Absolutely, and you know there is a, first of all incentives work.

– [Host] 100%.

– I mean for most of the economy, for most of society, incentives work, so why should they not work here? Doesn’t mean doctors are evil, it’s just incentives matter.

– [Host] Right.

– It’s, it’s a hard sell to, some of it is also I think people are just like, “Look, what I do for a living is important and it works.” And it might be a tough sell to say, “Well gee, maybe it doesn’t work.”

– [Host] Right.

– And try explaining to the next patient with chest pain that they don’t need a cath, I think is, it’s almost like, you know how it’s easier to just give them the antibiotic than explain why they don’t need an antibiotic.

– [Host] Exactly.

– This is sort of like that, you know, it’s just, “Okay, we’ll do the cath “because I don’t want to sit here,” and then you’ll go to another doctor anyway, he’ll do it.

– Yeah, because he’ll do it, you’ll always find someone who will do it.

– [Bill] Right.

– Well, so I want to close us out, because we’re coming up on 37 minutes, and I want to get it under 40 so we can share this, ’cause this is a fantastic discussion, man.

– [Bill] Good.

– And the comments are fantastic. Let’s bring this back to the vaccine issue, because we’ve been talking a lot about this lately. Vaccine issues where the science is settled, there is a lot of clear guideline and data, there’s a schedule, we have the algorithm that works, and there’s not a lot of variation in terms of how we ought to institute it.

– [Bill] Right, right.

– Now,the anti-vaccine guys and girls, they actually point out all the flaws in medicine that you and I are talking about.

– [Bill] Mm-hmm.

– And so in other words, that we’re paid to do things to people, that their incentives do matter, that there’s variation we don’t really know sometimes what something’s harming, however they go and take these correct instincts and truths.

– And apply them to there, yeah.

– And apply to the one part of medicine where it doesn’t apply.

– Right, right. It’s funny, I had, I promised my wife I wouldn’t talk about the family, but I can’t help myself. I’m not coming home till later tonight, she’ll be asleep.

– [Host] There you go, you’re probably not coming home at all after this, right.

– I’m in Vegas, after all, right?

– [Host] I know, let’s go party!

– I was at a family dinner, and somebody’s new boyfriend was there, and was anti-vaccine.

– [Host] Good Lord.

– And I, against my better instincts, went into there and said okay let’s talk about it. And it was like either he things I’m an idiot and I’m just saying the wrong thing and we’re all just idiots, or, there’s this vast conspiracy going on.

– [Host] Yeah, yeah.

– And what’s worse, I’m not in it, you know. I’m the guy who didn’t get the memo that there’s, I’m like, they say it’s not–

– So you’re even stupider, yeah.

– It’s like, I don’t know if I’d rather be insulted because you think the science is wrong or because you think I’m not in on the right meetings to find out the vaccines are no good.

– That’s the thing they keep saying we’re getting kickbacks, I’m like where? Am I the only one not getting the memo?

– Vaccines are the one area where you can’t say it’s done for the money.

– [Host] Right.

– For the most part.

– [Host] For the most part, yeah, yeah.

– In fact they have to have funds to protect the companies who do it so they’ll keep making it, yeah.

– Exactly right, we did a show on the vaccine injury court. We also did a show on the medical device and procedure FDA process, the you know five, 10K process, yeah.

– But for clinicians, I think if, like the reason the vaccine guidelines are so clear is because the science is so clear.

– [Host] Yeah.

– And I think good guidelines allow you to be firm where you can be firm, be flexible where you can be flexible, and have numbers, data, outcome, that can demonstrate to clinicians who are open minded to change. Like you know, gee, maybe the care of CHF has changed over the past 20 years, and maybe something is different now.

– I think that’s a perfect way to end, because what you’re basically saying in ZDoggish, is optimize 2.0 so we can transcend to 3.0, love and care for your patients, and the way you do that is you do the right thing for them transcendent of ego, and don’t hate the guidelines if they can help. Now do hate cookbook medicine because it’s too extreme.

– [Bill] Yes, yes.

– And do hate full autonomy because you wouldn’t want your pilot doing barrel rolls while another pilot’s flying by the book.

– A good example would be antibiotic stewardship programs.

– [Host] Right.

– So one area where docs have already been, you know, slapped, and said you are not allowed to prescribe vancomycin unless I say it’s okay.

– [Host] Yeah.

– And just, it happened, it went through–

– [Host] That’s onerous, yeah,

– But I’ve never seen a Cochrane review that was praising the evidence for its efficacy. I mean they were like falling over themselves saying yes this works. So that would be like an example of where limiting autonomy is not always a bad thing.

– Yeah, and you see, it feels onerous to the docs ’cause you have to call for approval.

– [Bill] Yes.

– But the truth is that’s the only way, and as a resident, I remember, I’m like, I’m ready to drop the guerrilla-cillin on this guy.

– [Bill] Yeah.

– Crap, I gotta call ID.

– Right.

– And then when you call ID, they say, “So tell me what’s going on.”

– [Bill] Yes, yeah.

– And suddenly you have this conversation where you got served, you got educated, you’re like, gee, I didn’t realize.

– Well in the beginning as an intern you’re basically like, look dude, I am just saying what the attending is saying–

– [Host] Yeah, the attending wants it.

– I’m gonna go back there, just yes or no.

– [Host] He’s gonna ream me.

– And then later on you can actually have a clinical discussion.

– [Host] Right.

– Where often, especially with the ID folks–

– [Host] Oh, yeah.

– They’re like, do you know in our hospital, the, I’m like, I don’t know, so.

– [Host] And now I know.

– Yeah, so they were willing to give that up.

– [Host] Right, Right.

– I guess because it’s less threatening, but that was an area, a model of, you know, it doesn’t have to be threatening that some decisions you have to run by people.

– Yeah, yeah, yeah, yeah. I am all into what you’re trying to do, Bill Rifkin, and if you guys want to learn more about what Bill’s doing, what MCG is doing, click the link in the description of the thing. It’s really, you’re a Z-packer too, man.

– Yes, yes.

– Like you watch the show.

– Yes.

– So we were talking about Donald Hoffman and the nature of reality–

– My wife is terrified that I’m going to be singing or something, I said no.

– [Host] Oh, should we do this right now?

– It was bad enough that I was trying to pull off the pink here.

– I think you nailed it.

– She’s like, “Really, you’re gonna go to Vegas in pink?”

– I think you nailed it, that’s the only way to come to Vegas.

– [Bill]Right.

– What happens here now goes out to everybody.

– Right, everybody knows.

– That’s right. So thanks Bill Rifkin.

– [Bill] Thank you.

– Thanks for coming out to Vegas, and guys, Z-pack, I want you to hit like, I want you to hit share, I want you to tell the world about how we can build 3.0 by optimizing 2.0, and rejecting the worst aspects of 1.0 while preserving the heart of it, which is the human relationship. All right guys, we are out.