Fix Healthcare With A Comic Strip? (w/Dr. Peter Valenzuela)

– [Zubin] Hey guys, ZDoggMD. Welcome to the show! Dr. Peter Valenzuela, welcome brother.

– [Peter] Thanks so much. Appreciate you having me here.

– [Zubin] Man, so Peter, the way we got connected is first of all, we worked for the same institution for a while.

– [Peter] Which shall not be named.

– [Zubin] Oh sorry! We can’t say it?

– [Peter] No, we can say it.

– [Zubin] Oh, are you sure?

– [Peter] Yeah, let’s do it. Go for it.

– [Zubin] Well we just did, so. So we both worked with those guys, and you were in leadership up in Northern Cali. And since then you wrote a book.

– [Peter] Yes.

– [Zubin] And we became buddies because it’s all about that physicians using creativity to point out what’s wrong with our system.

– Yeah.

– And this is why. So a lot of people are like why, you guys just keep complaining about what’s wrong. It’s like, no no no. 99% of solving this problem is naming it correctly, right?

– [Peter] Yeah.

– [Zubin] So you wrote a book called “Doc-Related.” And you didn’t wrote it necessarily, is that the past tense of write?

– [Peter] It has been written.

– [Zubin] It has been written. You wrote it and you illustrated it because what people need to know is that you are an artist. And this is basically like the Dilbert for medicine.

– [Peter] Yeah, yeah. Actually it’s funny, I started with the comics first. And then as I kept drawing comics, the more I wanted to tell the story as to why I was writing the comics. And I owe that to you. ‘Cause when you started with your music videos it was just a medium that was unusual, especially for healthcare, and it inspired me to think in a creative way of how do we share our story about what’s broken.

– [Zubin] That’s kinda awesome.

– [Peter] Yeah, no man, you’re my inspiration.

– [Zubin] Well I mean but this is why I thought this was so interesting because you were using art to manifest in a humorous way, but also very incisive. What drives us crazy in healthcare. And by the way, I gotta give a shoutout to your wife. She brought, she makes wine too.

– [Peter] Yeah, she does.

– [Zubin] Look at this. What is, oh there it is, Woo Girl! Where is it? So we’ve been having a few sips of the bubbly here.

– [Peter] Yeah, a little bubbly.

– [Zubin] This is a Pinot Noir sparkling wine. Pinot Noir based rose.

– Yeah thanks, Vivian started her label earlier this year, so having lived in Sonoma County, she really got into it when we were there.

– [Zubin] So both of you guys are taking the creative aspect of life and actually just inhabiting it. ‘Cause you’re currently the medical director, the chief medical officer for Mercy Medical Group up in Sacramento, yeah?

– [Peter] Yeah, that’s correct.

– [Zubin] Yeah, so you moved recently, and part of it was be closer to that winemaking experience and be able to do that, but also, it just was a good fit for you in terms of leadership because what people need to understand is you’re not, you’re a family medicine doc, but you’re also in healthcare administration.

– [Peter] Yeah.

– [Zubin] And what’s that been like?

– [Peter] It’s a little schizophrenic. Most people are like you’re either this or you’re that. But I’m lucky enough to be both. I still see patients, I still practice medicine, but now I help to oversee a medical group of about 500 physicians. And I think that a lot of that is really being able to speak their language and understand where the headaches are and do my best to try to help support that and help address the problems.

– [Zubin] So this is what’s crazy because this book, which people should check, it’s on Amazon, we’ll put a link.

– [Peter] Yeah.

– [Zubin] It’s nuts because that someone in leadership in healthcare is naming these problems as clearly and incisively as this is insane to me. It’s a sign that we’re actually gonna approach health 3.0 because when even leaders can openly say here are all the problems and we need to work on these together, then we’re in a position to actually change the problems.

– [Peter] Yeah, I agree completely. I think for the most part we’ve just kinda… Most people learn to deal with it. And I don’t think we should learn to deal with it. I think we need to figure out how to solve it, right? What do we do differently? How do we make things better for our patients and for our physicians and clinicians and the people on the frontline?

– [Zubin] Yeah, and look at just the chapters here, man. Like “Health Insurance: Will This Be Covered?” Prior authorization. Tell me about “Health Insurance: Will This Be Covered?”

– [Peter] Oh man, jeez.

– [Zubin] Why did you write that chapter?

– [Peter] Gosh, don’t even get me started. I think a lot of docs right now are dealing with patients who have high-deductible health plans. And the first thing patients ask when you’re seeing them and you say I really think maybe an MRI or a CT might be helpful for you. For those people that are having to shoulder more out-of-pocket costs, the first thing they say is “How much is that?” And I think what’s challenging for docs is that not all of us know the prices of these things. And unfortunately we live with EMRs that don’t give you that type of information. We should have an EMR that says this person has this health insurance, and this plan, and this deductible, and this is what we think it’s gonna be. Instead we’re left with well we could call and check around, or maybe it’d be good for you to call, and it’s just part of the insanity of what we have to deal with on a regular basis.

– [Zubin] Dude, it’s like one thing that technology is good at is aggregating things like prices and doing the algorithmic stuff that doesn’t require humans.

– [Peter] Totally.

– [Zubin] Doesn’t require a human to do that. And what you’re asking now is you’re asking physicians who are super busy, already data overloaded, they’re already data entry clerks, you’re asking them to also be the arbiter of the finances for the patient. Now this is the thing, if they don’t do that, and no one does that, you’re committing financial assault on this patient. Because they have no idea what this is gonna cost.

– [Peter] Yeah.

– [Zubin] And nobody does that. Even mechanics don’t do that. They give you an estimate, right? So the lack of price transparency and the lack of a physician’s ability to know that answer creates a kind of moral distress.

– [Peter] It does.

– [Zubin] And so what you said about why can’t the EHR just do this. Why can’t it?

– [Peter] I have no idea. I think there’s platforms out there now that are getting a lot better at being able to identify prices for patients and for consumers. And I still grimace a little bit when I use the word consumer because as a physician you see patients and you want to do what’s best for them, but now we talk about consumer-driven care and unfortunately a lot of our consumers aren’t educated enough or informed enough to be able to make some of those key decisions so we need to partner with our physicians and clinicians to help support that.

– [Zubin] There was a study recently, I forget exactly where, but they were looking at doctors. Or maybe it was an article written by someone. Even physicians can’t make consumer-level choices in healthcare. They don’t have the information necessary to do it, and when they’re patients, the power dynamic changes and they become as helpless as anyone else a lot of the time. So if our own physicians can’t do it, how can we ask our patients to be educated consumers when they don’t have access to transparent data?

– [Peter] Yeah. I think you said it really well. I mean I kinda hobbled in today, right?

– [Zubin] Yeah!

– [Peter] Because I had

– [Peter] arthroscopic knee surgery on Thursday. I gotta say, even myself, I was really struggling with okay what is the explanation of benefits here and what’s covered and what’s not. I signed off on a few things, and now I’m thinking I’m sure in the next month I’m probably gonna get two or three bills, and I don’t know how much of that is gonna be covered, But I wish there was a way to really understand that ahead of time so that we don’t have to deal with it on the backend.

– [Zubin] Yeah. I mean I’ve had the same struggles and I’ve talked about them publicly and I’ve had people on the show talking about this. Marshall Allen and others, Marty Makary talking about price transparency. I mean it’s a huge problem. And so when you when you started writing this book I bet you got pushback from others in leadership. Because basically what you’re saying is here are all our problems, and it’s not just externalizing it to insurance companies and prior auths and things like that. It’s also leadership stuff.

– [Peter] Yeah.

– [Zubin] Right?

– [Zubin] Which we’ll talk about. But so did you get a lot of crap for this?

– [Peter] I did. It’s funny, I have people who have followed my comics for years and they love my comics. Like you said, it’s been called the Dilbert for healthcare.

– [Zubin] And you have a website that we could send people to, “Doc-Related,” yeah?

– [Peter] I do, yeah, Doc-Related.com. And it’s got all of my comics in there. And the comics vary from EMR to leadership to provider performance to patient satisfaction, to pre-authorization, all those things that you would see in a daily part of… As part of your daily work as a physician. And they’re more satirical, right? They’re the headaches that we deal with.

– [Zubin] Yeah.

– [Zubin] And I’ve had some physicians, and I shouldn’t say physicians, I’ve had some administrators and managers that are not clinicians who’ve come to me and said “I really feel like you’re taking a jab “at administrators here.” And what I tell them is I’m not taking a jab at people directly. I’m actually dealing with the headaches of healthcare. Right? What I’m talking about, what I’m creating, what I’m drawing, what the comics we’re making, are based on what people across the United States are dealing with every day in healthcare situations. And I think that for the most part, being on both sides as an administrator and a physician, I can laugh at some of this, you know? I know the schizophrenia that goes on behind the curtain. The discussions that are had away from patient care that most people aren’t aware of. And it gets pretty dicey.

– [Peter] It gets dicey because you’re having to make compromises. And you’re trying to keep the lights on. You’re trying to keep employees, staff, doctors happy. You’re trying to take care of patients. You’re trying to deal with compliance and regulation. All those things, and they can pull you in different ways. People don’t understand this as well as they understand it for say doctors, nurses, respiratory therapists, physical therapists, that moral injury happens with administrators too.

– [Peter] Yeah.

– [Zubin] And especially with clinical administrators who know our obligation to the patient better than anybody, right? So it’s interesting, you’ve outlined this thing into three parts, part one, two, three, and one is “Human Dynamics.” So you, in chapter one, introduce all the characters, right? Who are some of the characters that you have?

– [Peter] Well I’ve got multi-generational, multicultural physicians and clinicians and administrators that are all, it’s basically the setting of, if you’re gonna do an Office Space for a clinic, that’s basically what you got, right? You’ve got a manager named Donna who’s the person that oversees the day-to-day affairs of the clinical operations. You’ve got a physician leader in Dr. Stevens. You’ve got an older doc who was recently acquired named Dr. Katz. And between the two of us, Dr. Katz seems to get the most amount of reads and reviews because patients seem to relate to him, or people seem to relate to him the most. He’s just somebody that’s in his early 60s who was recently acquired, who really is nostalgic for the old ways of practicing medicine that wasn’t EMR driven. There was really a lot more autonomy. And I’ll caveat this with saying this, my characters are not about age-ism. They’re not about anything related to stereotypes of what you see. They’re really amalgamations of people that I’ve met through the years. I’ve been practicing medicine for 20 years And I’ve dealt with different people and different personalities. And so my characters are really created through little tidbits of different people I’ve encountered along the way.

– Yeah, Katz is a really impressive one ’cause he’s like the voice of ancient reason. He’s like Health 1.0’s voice. Like hey, remember we used to do it this way? Why is it so screwy? He points out all the screwy stuff. But the truth is, you and I both know, going back to the days of Health 1.0 isn’t the answer. It’s not the highest practice we can do. We need to transcend that. And what Katz does is he points out hey guys, before we get lost in the sauce of performance metrics, and click boxes and charting and electronic health record, and throughput, and RVUs and all the other metrics that as an acquired… When you say acquired, he was probably in private practice or a different group and some big group bought his practice.

– [Peter] Yeah, yeah.

– [Zubin] And now he’s basically saying But guys, it’s still about taking care of the patients and us not going crazy.

– [Peter] Yeah.

– [Zubin] Is that how you see it?

– [Peter] No, it is. And it’s funny, one of my favorite comics that I have includes Dr. Katz where he’s talking with another physician and they’re talking about the new medical director for quality. And Dr. Katz tells the other doctor “Hey, have you met the new medical director for metrics?” And the doctor’s like, “What are you talking about? “You mean the medical director for quality?” And he goes, “Yeah, no, for metrics.” He said, “It’s got nothing to do with quality. “It’s all about the metrics.” And it’s really just kina that, right? I mean we have, when you think about metrics, we’ve got 1,700 metrics that CMS has created for us to follow across the hospital setting, ambulatory setting, nursing facilities and other. 1,700, right? You’ve got another 80 HEDIS metrics, you’ve got another 57 that Joint Commission has in the hospitals. I mean we were metric crazy. And the sad part is we’re trying to measure things that may not necessarily truly impact patient outcomes. When you look at what we as physicians do, and this is a humble thing to say, only 10 to 20% of what we do impacts patients’ overall healthcare.

– [Zubin] Yeah.

– The other 70, 80, 90% are really social determinants of health. The things they’re doing when they’re not in the hospital, when they’re not in the clinic, right? It’s what they’re eating, it’s if they’re exposing themselves to hazardous materials or dangerous stuff. It’s only a part of their overall health. And I think we have to really look at how we provide services in a different way and partner with patients and look at other avenues to truly make them healthier.

– [Zubin] Yeah. And basically what you said is the basis of a Health 3.0 approach which is hey, if 80 to 90% of social determinants of health in their life, we’re only intersecting with their life in a tiny way. Why have we blown it up into this, what Jonathan Bush, formerly of athenahealth, has called the administrative technocracy. So the metrics police, the click box police, all the other CMS regulations, all that.

– [Peter] Yeah.

– [Zubin] All of this to turn a patient into a commodity which is a throughput RVU measure that generates revenue. When our benefit to that patient is this, unless we’re doing it smart, and we don’t do it smart. We’re in a transition phase, so there’s nothing wrong with quality measures that measure quality.

– [Peter] Yeah.

– [Zubin] But they become metrics when they don’t measure quality.

– [Peter] Yeah. And I think what what’s so difficult about quality metrics, number one, is that they’re hard to pull. Most people have to do them manually because our EMRs are not savvy enough to abstract or extract that data, so we have to hire people to track our quality metrics.

– [Zubin] Which by the way, a piece of technology has one job. Do what technology can do that humans don’t do that well that technology can do better. Abstracting that stuff is exactly what it could do.

– [Peter] And we’re not even uniform with our quality metrics. If you look at one insurance plan to the next they have different–

– [Zubin] Different.

– [Peter] Different variables. For hemoglobin A1C and blood pressure. Even the ranges are variable, right?

– [Zubin] So you have to serve multiple masters, often at conflict with each other.

– [Peter] Yup.

– [Zubin] And you have to serve your conscience to take care of the patient. And to keep the lights on financially. So this is where the moral injury starts.

– [Peter] No, totally. And then when you think about quality metrics that matter to patients and physicians.

– [Zubin] Yeah, yeah.

– [Peter] I’ve got cardiovascular surgeons and others whose quality metric is a statin or blood pressure, and I think that’s okay. But when you think about it, they say, I’d rather have something more relevant to my specialty, right? I’d rather be able to measure something that matters to the patient that’s something that I care about. And we haven’t really built up standard metrics that matter in a way that’s gonna affect patient care.

– [Zubin] Right. In a way you could fall into the trap of reductionism with metrics and just say we’re reducing everything to a cholesterol value. When in fact we know cholesterol is just one manifestation of many, many, many, many, many, many things. And in fact, some people with good genetics can have crazy cholesterol and be fine. Some people with bad genetics can have normal-looking cholesterol and be not fine. There’s inflammation, there’s many other aspects of this, and then there’s the patient’s hopes, dreams, and fears. What do they actually want? They want to live forever, or do they want, they have certain goals, they have certain functional goals, certain psychological goals, certain spiritual goals. We don’t have metrics for that.

– [Peter] Yeah.

– [Zubin] And I don’t think our AI is ever gonna get smart enough to generate metrics for that. So what we oughta do is have the EHR make do with anything that is measurable that actually makes sense and take it off our plate so we can do the intangible stuff that requires a human consciousness.

– [Peter] Yeah.

– [Zubin] Yeah? And I think that that’s one of the themes that goes throughout your strips is that, what we’ve done is we’ve stripped out the humanity from the heart of this medical thing and we’ve turned it into this business Dilbert-like creation. And everybody’s suffering. Patients are suffering. Your chapter two is “Patient Surveys: The Quest For Positive Reviews.” What’s up with that, dude?

– [Peter] Oh man.

– [Zubin] This is a triggering topic.

– [Peter] Oh jeez.

– [Zubin] I need more wine.

– [Peter] I’m telling you. Hopefully we got more bubbles coming. But I think–

– [Zubin] Gonna pour me some Woo Girl. By the way, does your wife have a website for this?

– [Peter] Actually she does. It’s www.woogirlcellars.com.

– [Zubin] All right, I’ll put that in the show notes, yeah.

– [Peter] Yeah, appreciate that.

– [Zubin] ‘Cause it’s good. It is really good.

– [Peter] Well thanks, man.

– [Zubin] Yeah, fantastic.

– [Peter] Appreciate that.

– [Peter] I don’t know why I’m taking credit for it. She made it.

– [Zubin] It’s got notes of chocolate, notes of…

– [Peter] Spoken like–

– [Zubin] Is that pube that I detect?

– [Peter] Well I hope not. Yeah, spoken like a sommelier who doesn’t want a job.

– [Zubin] She’s off camera going, “No, no pubes!” Spoken like a sommelier who doesn’t want a job.

– [Peter] Does not want a job.

– [Zubin] I don’t want a job.

– [Peter] Yeah, you need the little golden thing though, the cup. What does a sommelier use? Don’t they use something like that?

– [Zubin] Yeah, it’s like a little affectation that they wear, yeah.

– [Peter] Sorry man, my ADHD kicks in.

– [Zubin] Dude, hey, join the club. Squirrel!

– [Peter] Squirrel!

– [Zubin] Yeah, so what were we talking about?

– [Peter] So patient satisfaction.

– [Zubin] Yeah, thanks for bringing it back.

– [Peter] So patient satisfaction is really one of those love/hate relationships that doctors have, and clinicians for the most part. Because one of the things we want to do is make sure that our patients are happy with the service that they have. But somewhere along the lines it kinda got messed up in that we started getting graded for it, right? CG CAHPS came in and started saying we’re gonna grade you on patient experience. And just to be clear, patient experience and patient satisfaction are two totally different things.

– [Zubin] How so, how so? Explain that.

– [Peter] So patient experience is whether something that was expected to happen actually happened, right? Did the physicians see you within 15 minutes of your scheduled appointment, right? Patient satisfaction was, did you feel like the parking was close enough to where you needed to be to see the doctor? It’s a lot more subjective, right? It is the expectation that the patient has of what should have happened.

– [Zubin] I see, so one is much more subjective, one is measurable and objective.

– [Peter] One tries to be measurable, tries to be.

– [Zubin] Did they call you after the visit to follow up on X, Y, and Z–

– [Peter] Exactly.

– [Zubin] It’s patient experience.

– [Peter] Did the physician review your medications with you during the visit?

– [Zubin] I see.

– [Peter] Right? Where patient satisfaction is more like, did you enjoy your visit with the doctor.

– [Zubin] Right.

– [Peter] And when you deal with patient experience, that’s a metric that CG CAHPS uses to help grade us, and it’s also way that organizations get incentivized. By default they incentivize their physicians the same way based on their scores. And the thing with patient experience, I’ll start talking about that first. Patient experience is really a very small window of excellence. And when I say that, I mean you could have a raw percentage score of 85% of your patients say that you did an awesome job, right? And that puts you in the 50th percentile of your peers in the nation.

– [Zubin] Wow.

– [Peter] You could have 90% of your raw percentage say you did a great job. And that now puts you in the 90th percentile. So like a five to seven raw percentage score swings you from average to above average.

– [Zubin] Yeah.

– [Peter] It’s because that pool is so close, right? And we already know that patient experience scores are based on okay, when the survey was sent, how the survey was sent, right?

– [Zubin] Absolutely.

– [Peter] How many people responded to the survey, right?

– [Zubin] There’s a selection bias.

– [Peter] Whether your sample size was big enough, there’s all that stuff. Patients Sat, I’ll talk about Patient Sat now. So Patient Sat is really the expectation patients have. And I think patients should be really happy with their experience. The thing is, you as a physician can do a really good job with your patient and making sure that you monitor their blood pressure, their medications, made sure that they got their screens done, and the patient may leave there and say “I just didn’t feel like he did what I needed him to do.” And nine times out of 10, and you’ll know this because one of my favorite videos that you made is Blank Script.

– Oh yeah, about narcotics.

– Nine times out of 10 it is the patient saying “I am expecting you to do something for me.”

– [Zubin] Yeah, antibiotics.

– [Peter] Antibiotics.

– [Zubin] Narcotics, pills to solve the problem.

– Every time I get sick like this I know that it’s bronchitis and I just… I’m gonna be flying out of town, I need you to write me a script.

– [Zubin] The only thing that helps me starts with a Z.

– [Peter] Yep.

– [Zubin] A Z-Pak.

– [Peter] I need a Z-Pak, right?

– [Zubin] Yes, exactly.

– [Peter] Same thing with pain, right? Anytime I have this injury, this is what I get.

– [Zubin] Yup, the only thing that helps me starts with a D. Dilaudid.

– That’s right. And I think as doctors we try to do the right thing. Unfortunately it may not be what the patient wanted. So that, it leads to that patient satisfaction or dissatisfaction.

– [Zubin] And this is where patient experience and patient satisfaction can actually be at odds, because a patient experience metric may be, their pain was addressed in some way. Bio-psycho-social addressing of the pain.

– [Peter] Yeah.

– [Zubin] Whereas satisfaction may be, it needs to be addressed in the way that I expect it addressed as a patient, and that may not necessarily be the way that is best for me.

– [Peter] Yeah.

– [Zubin] Yeah, and there was some data, and I don’t know if it’s now been debunked or not, but that higher patient satisfaction scores correlate maybe with worse outcomes for patients.

– [Peter] Yup. It’s in my book actually. I quote some of those datas.

– [Zubin] Nice!

– [Peter] I’m here with you, man.

– [Zubin] Hey, this is why we get along.

– [Peter] Yeah, I mean UCSF did a lot of studies around that. And it showed that physicians are… Physicians who score highest on patient satisfaction in some circumstances were those that were more likely to do whatever it was the patient needed of them.

– [Zubin] Ah.

– [Peter] And actually I have a comic, I have a few comics in that chapter. And one of my comics has Dr. Katz in it and it starts with the manager talking to the operational leader. And the operational leader says, “Donna, Dr. Katz, man, he’s killing it with CG CAHPS scores. “His Patient experience scores are fantastic. “Why don’t you go ask him what he’s doing so that maybe “we can teach the other doctors what it is “his secret sauce is so that they can do better.” So Donna goes to meet with Dr. Katz and she says, “Dr. Katz, you have great patient experience scores. “I mean, what’s your secret?” And Dr. Katz looks at her and he goes, “It’s simple, I just give patients prescriptions “for whatever they ask for.”

– [Zubin] That is such an old school move.

– [Peter] And I know it’s not… Again, it’s satire, right?

– [Zubin] No, but it’s not! But it’s not!

– [Peter] But statistically, when you read the stats around patients who are most satisfied, who have chronic diseases, those patients with the higher satisfaction scores actually have higher mortality rates in the hospital because there are certain things that might’ve been… They might’ve been provided that were unnecessary.

– [Zubin] So as the Rolling Stones say with Satisfaction, “You might not get what you want, “but you just might get what you need.”

– [Peter] To need, yeah.

– [Zubin] If you get a good doctor. This was looked at, again, athena’s research guys, I remember we did a show about this, were looking at… They were looking at their EHR pool of data and saying, hey, when is it that doctors are more likely to give inappropriate antibiotic prescriptions. Well it turns out it’s later in the day when they’re tired.

– [Peter] Yeah, end of the day, man. I don’t wanna spend 30 minutes–

– [Zubin] Don’t wanna spend 30 minutes telling this patient that this is is a viral illness. And now with COVID, man, those discussions get even more complicated. Hang on, I’m just gonna grab a…

– [Peter] Sure.

– [Zubin] I realized that my recording box is causing a lot of noise. And we don’t edit this show, so. I’m gonna put this little dampener over here to keep it from pissing off my mic. All right, back to you, Bob. You’re not Bob, you’re Peter.

– [Peter] Yeah, no worries.

– [Zubin] So the patient satisfaction thing is a huge driver of dissatisfaction among healthcare professionals.

– [Peter] Yeah.

– [Zubin] And you tap into that. Nurses in particular feel like this is… Are we supposed to be… Does RN stand for, what was it, refreshments and narcotics basically. And the truth is no, that’s not what it stands for, right? And the more that we can bring this to the fore in terms of understanding, now that doesn’t mean that the patient experience doesn’t matter. In fact, it matters a lot.

– [Peter] Yeah.

– [Zubin] It matters a lot. Imagine, I actually heard that the… A big patient satisfaction organization, one of these metrics monsters, part of what I call the measurement industrial complex that has sprung up around measuring these things, actually told me a beautiful story. And they said here’s an example of patient experience. A woman in the hospital has a miscarriage. What is that patient’s experience from the time they come in to the time that they leave? This is an emotionally horrible event. Are they given resources? Are they treated well? What’s the tone of the staff? How is their experience? Are they supported? And then you start to go that is actually crucially important.

– [Peter] Yeah.

– [Zubin] Because you can traumatize someone even more than they’re traumatized if you don’t understand how that’s done. But how do you measure that, right?

– [Peter] Yeah, and that’s a great story. I mean I always reflect on, I think it was Cleveland Clinic that had this video. It still tears me up, but it’s all about empathy, right?

– [Zubin] Oh that one. Yeah, the empathy video.

– [Peter] It’s a black and white and it’s got different people in the hospital setting. It kinda bubbles, there’s a bubble thought on what’s going on in that person’s head or what’s going on in their situation. And that’s the thing is, we don’t always speak it, but people may be going through a lot of stuff.

– [Zubin] The most belligerent patients, that seem the most seem the most intransigent, if you really were to inhabit what’s inside them, you would just feel nothing but compassion.

– [Peter] Yeah.

– [Zubin] Right? And that’s the problem is we don’t have the bandwidth for compassion.

– [Peter] Well I mean try doing it in 15 minutes, right?

– [Zubin] Right.

– [Peter] You’re treating somebody for their diabetes and hypertension, and cholesterol and depression. Most people are really struggling with that right now.

– [Zubin] It’s worse now, yeah.

– [Peter] And trying to chart, and trying to code, and trying to make sure you capture quality metrics, all while trying to provide that care that that patient needs for you at that time. It’s a lot.

– [Zubin] It’s a lot.

– [Peter] And I don’t want to this to sound like we don’t care about patients. We really do care about patients, and that’s what’s contributing to the moral injury We’re all feeling, right? Is not being able to do what we need. I think patient satisfaction, patient experience… The goal of that should be to improve outcomes for patients so that they can get better experiences and better lives. Somehow along the line it got kinda… It kinda bifurcated into this… We’re now going to do Yelp scores on you, and let you know how you’re doing on Yelp. And unfortunately when they do this, there’s not even a big enough sample size to say whether somebody did a good job or not.

– [Zubin] Five reviews.

– [Peter] Right!

– [Zubin] And they’re usually biased towards people who are angry, yeah, who are willing to go on Yelp and tear you a new one.

– [Peter] I’ve got a comic also that’s talks about Yelp. And not to slam Yelp, ’cause I love Yelp for restaurants.

– [Zubin] For restaurants, yeah.

– [Peter] But that also inspired a comic from me, right? You’ve got a comic where there’s a manager talking to a physician that says “I really need to talk to you “about your patient satisfaction scores.” And he says “Well I thought I was doing great on CG CAHPS.” She goes, “Yeah, you are, but you’re “not doing great on Yelp.” And he says “Well, I refuse to be rated by an organization “that rates restaurants along with physicians.”

– [Zubin] Yeah. It’s demoralizing. Because they’re not the same… You could argue they’re both a service industry. but it’s a different magnitude.

– [Peter] Yeah.

– [Zubin] Restaurants have a certain process and expectation. Now that’s not to say that we can’t learn from certain aspects of hospitality.

– [Peter] Yeah, but–

– [Zubin] But, yeah.

– [Peter] Well and that’s when design thinking comes in.

– [Zubin] That’s right.

– [Peter] I mean, we can apply design thinking to make sure to improve someone’s, like you said, the experience of having a loss, right? A miscarriage or whatever. Walk in that person’s shoes and say what are the core things they’re gonna need to be able to help them.

– [Zubin] That’s right, yeah. That’s right.

– [Peter] And we could do it well.

– [Zubin] Yeah. We don’t utilize our chaplains enough, there’s so many different resources. Hospice, all this stuff is underutilized. ‘Cause it’s not reimbursed.

– [Peter] Nope.

– [Zubin] Yeah.

– [Peter] It’s not.

– [Zubin] Which you have a chapter on coding, “What’s The Code For That?” Right? So much of our time is spent trying to figure out how to get paid.

– [Peter] Yup.

– [Zubin] Yeah, it’s crazy.

– [Peter] Yeah.

– [Peter] I think it’s funny, coding is a whole other animal in itself, right? And it’s funny, when physicians hear coding some of them just literally–

– [Zubin] They start to seize.

– [Peter] Yeah, right? I mean the whole coding thing started, and it’s in my book, I talk about the history of how coding started.

– [Zubin] Very cool.

– [Peter] It was actually based on, in England, in London times, back 17th century, they used this thing called London Mortality Bill to track what people died of.

– [Zubin] Ah.

– [Peter] Right? So from the 17th century into the 18, 1900s, it was used to measure how people died. And then in the early 1900s, 1920s, 1930s, the World Health Organization kinda took it on and it got named from International Classification of Death to International Classification of Diseases.

– [Zubin] ICD.

– [Peter] And they started tracking what people were sick of. And I think that once we started doing that, which was a good reason, we started trying to capture every single disease that people had. And then we started trying to figure out how do we give people credit for seeing these diseases. And it just blew up, right? We went from 17,000 codes to 70,000 codes. Now we’ve got CPT codes, now we’ve got all kinds of different types of codes that we’re dealing with. And our physicians… As physicians, clinicians, we’re not trained to really say okay, this person has heart failure. Okay, well what type of heart failure do they have, right? Is it right-side heart failure with an ejection fraction of this? What is that?

– [Zubin] Acute, chronic? With or without hypertension?

– [Peter] As a clinician, it’s not gonna change how I treat the patient, but now I’m in this game where I have to capture the exact ICD-10 code to make sure that I’m given full credit for the work.

– [Zubin] Right, right. And it becomes just another cognitive load on a physician whose cognitive bandwidth should be reserved for caring for this patient, doing the intuitive, high-level medicine that only human beings can do.

– [Peter] Yeah.

– [Zubin] Whereas you would imagine that, if that’s important, if it is important to have all these ICD codes and all that, just let’s say for data tracking or epidemiology or whatever, for other science. Then have the computer figure it out.

– [Peter] Yeah.

– [Zubin] Have the computer listen to natural language in the visit and translate it into codes that make sense.

– [Peter] I mean there’s programs. There’s AI now literally where you can have a device, and I’ll throw a shoutout out to Robin. A Robin device that’s a little… It’s like a little AI device that you put on your table so that when you’re seeing the patient, you actually are talking to the patient–

– [Zubin] Heaven forbid.

– [Peter] Looking at them eye to eye, and you’re saying what’s going on with them. And Robin is able to pick up the diagnoses, any kind of CPT codes, any kind of HEDIS metrics, any RAF components, all while you’re doing your focus on the patient.

– [Zubin] That’s key, that’s key.

– [Peter] I mean we need to figure this kind of stuff out.

– [Zubin] There’s a startup here in town called Suki.

– [Zubin] S-U-K-I.

– [Peter] Yeah, I love Suki.

– [Peter] They follow me.

– [Zubin] We had them on our show. They do? Oh yeah, yeah, yeah. And they do similar stuff. It’s kinda like hey, take the stuff off the plate. That’s, we talk about AI all the time. AI’s never gonna replace doctors. It’s gonna be a tool we use.

– [Peter] No, yeah.

– [Zubin] To make our lives and the lives of our patients better. And that’s gonna be key. So that was coding. Now you have a chapter here, “Leadership and Communication: What are you Saying?” That’s the name of the chapter. This is good.

– [Peter] Oh man.

– [Zubin] You gotta tell me about that.

– [Peter] Oh jeez, so leadership and communication–

– [Zubin] This is where you get yourself fired from your group.

– [Peter] Pretty much. This is the… It is that challenge, the arm wrestling that occurs between people on the frontlines, and administrators and managers. I’ve been in meetings where I’ve literally listened to CEOs and other executives say, We are doing fantastic. We are killing it on our dashboards. We’re hitting every metric we need. We’re doing wonderful. And I’m sitting there thinking I just left a meeting with a bunch of physicians and staff where they’re talking about not having enough support staff, when they’re talking about not having the call center appropriately directing calls, where they’re talking about things that are vital to patient care, but no one is really listening to them because the dashboard metrics don’t have any of that included in there, right? And so it’s like docs and administrators are speaking two languages.

– [Zubin] Two different languages, right.

– [Peter] I always joke around that I… I was in private practice in west Texas, and after a couple of years of being in practice, I actually went back to school to get my MBA because I didn’t know the business side of medicine.

– [Zubin] Yeah.

– [Peter] And I was fortunate to do that. And when I came back, it kinda opened my mind up to different ways of seeing things. But one of the things I always joke with docs about is, I told them I went to get my MBA so I could speak the language of administrators, right? So I tell our docs, I was like “Okay man, anytime you hear an administrator come to you and say hey, listen, this is a big opportunity for us. I said, “When you hear the word opportunity, “opportunity translates to things we suck at.” So any time you hear the word opportunity, it means we’re doing a terrible job here and these are things that we suck at.

– [Zubin] Got it.

– [Peter] Right?

– [Peter] When you hear people use the word, “This is gonna be a journey for us,” I say that translates to “Things that suck to go through.” So be prepared, right?

– [Zubin] That makes sense!

– [Peter] Totally.

– [Zubin] You could be like a professional leadership to doctor translator.

– [Peter] Dude, I’m like a translator, an interpreter. You name it.

– [Zubin] Dude, that’s great.

– [Peter] It’s those types of things that I think happen with physicians and clinicians.

– [Zubin] This interview’s gonna be a journey for us, Peter. We’re gonna go through a lot of–

– [Peter] I think we have a lot of opportunities to identify things.

– [Zubin] We have a lot of opportunities to really… I love it. You know what doesn’t have a lot of opportunities or a journey? This wine, it’s delicious.

– [Peter] Is that right? Oh my God, nice. Okay, wine break.

– [Zubin] Oh man, dude. See, this is… The more you talk, the more I’m like this is what we need is this connection between leadership and frontline caregivers that has been tenuous, in some organizations really good, in some it’s just like, oh my god, really? It’s exactly what you said. Oh we’re doing great, we’re crushing it on the metrics. And then one room over people are crying ’cause they’re understaffed. They’re ready to quit, they’re ready to go take a traveling nurse job at 3X the pay because they’re just not gonna do this anymore.

– [Peter] Yeah.

– [Zubin] Right?

– [Zubin] And COVID has made it worse, don’t you think?

– [Peter] I agree, I mean I think it’s made it really tough. I think about… One of the examples I listed in the book is around call centers, right? And I think call centers can be good when done well. I think that they can also not do so well.

– [Zubin] Yeah.

– [Peter] There was a study that showed what’s the difference between the mind of physicians versus managers and administrators when it comes to overall perspective of healthcare. And in the research they showed an example of call centers and what it meant to different people. Now the perspective from the administrators and managers was that call centers are wonderful. They’re the end all, be all, they’re gonna solve everything, they make things less expensive, which is partially true. And they use metrics like time to answer the phone, right? And turnaround time to message, right? And their metrics were always great. But when they looked at the physicians and they asked the same question, how do you feel about the call center, they would say the call center has been nothing but a headache for us, right?

– [Zubin] Yeah.

– [Peter] The good news is they’re answering the phone. The bad news is they’re just sending messages to the back of my office, so I ended up having to deal with them, right? The good news is they’re scheduling patients, the bad news is they’re not scheduling appropriately for the visit that they need. So they schedule a 15 minute appointment and I’ve got 30 minutes with them that I need to be able to solve.

– [Zubin] Oh.

– [Peter] So these little disconnects are the things that we have to work on together. When you look at leadership in healthcare organizations, and this might be blasphemy to some people listening, but the best running facilities are facilities that are being run by people with clinical backgrounds.

– [Zubin] Hell yeah! I will triple down on that.

– [Peter] Statistically.

– [Zubin] Statistically.

– [Peter] Studies show that.

– [Zubin] You talk about follow the science in COVID. Okay, here’s “the science.” Clinical people are better leaders in organizations that take care of patients, full stop. More profitable, better patient satisfaction and experience, less turnover.

– [Peter] Preach!

– [Peter] Preach, man.

– [Zubin] All of it.

– [Peter] Preach.

– [Zubin] All of it. And you’re one of those people because you’re a family medicine doctor practicing and a leader.

– [Peter] Yeah.

– [Zubin] So you’re biased, so the whole thing we just said is horseshit. It’s all just confirmation bias. Back to you.

– [Peter] No, no, but that is part of it, right? And they asked Toby Cosgrove, right? Cleveland Clinic Guy.

– [Zubin] Yeah, Cleveland Clinic.

– [Peter] Ran one of the best organizations in the country for years. They said “Why do you think that clinicians are better “in leadership roles in healthcare than others?” And he said, plain and simple, “Credibility.”

– [Zubin] Yeah.

– [Peter] He said physicians and clinicians have credibility because they understand the people on the frontlines, and those caring for patients in a different way. And it’s not to slam non-medical people.

– [Zubin] We need them too.

– [Peter] It’s just to say that if we’re truly gonna impact care and change the way we provide it, and provide better outcomes, we need people that can think from a clinical perspective on how to do it better.

– [Zubin] So let me play devil’s advocate for a second because I can see the comments already, because a lot of… And this is usually both doctors and nurses and other healthcare staff who will say Yeah, it’s one thing to have clinical experience. It’s another thing to be a total sellout, be so detached from the frontlines that you’re now drinking that whole “opportunity/journey” Kool-Aid and you’re not, you’re not in touch anymore and it’s actually even worse because you have the credibility of a frontline clinician, but you’re behaving like one of the worst MBA, like totally disconnected money-driven people. How do you think about that?

– [Peter] Yeah, I think that’s a great question. And speaking as someone who’s probably seen that way, or has been seen that way in the past.

– [Zubin] The dark side.

– [Peter] The key, and I mentioned that in my book, I think the key to improving those relationships is to walk in each other’s footsteps, right?

– [Zubin] How do you do that?

– [Peter] I’ve been in organizations where administrators, non-clinical administrators spend the day, or even the week shadowing their staff, right? Getting to understand what are the headaches they’re dealing with, right? What are the things that I’m not seeing in my ivory tower that people are struggling with. The flip side of that is having physicians or clinical staff also do the same thing. Being present for some of those major meetings that others have around, do we continue this service, right? You end up having ethical discernments around, okay, can we continue to have an inpatient rehab facility in this hospital knowing that most of these patients have no funding and where there’s no way that we can continue to support it. Include the clinical people in some of those decisions as well. Because you start understanding from both sides what it is their struggles are. One side has to keep the lights on. The other side has to keep the patients alive and doing well.

– [Zubin] Yeah.

– [Peter] And you have to have that partnership, and I mentioned dyad relationships for that reason. You have to have partnerships that have nonclinical and clinical people working together to solve their problems together.

– [Zubin] Got it, so you have both of them. Now there’s a couple followup questions to that. And one of them is, in the setting of coronavirus and people really having this great resignation where they’re like this is enough. I don’t feel valued by leadership. I have people tell me they don’t even give us lip service to what we’ve been through. They’re asking us to work overtime, and then they’re hiring travelers at 3X a thing ’cause everyone’s quit. And I’ve had, then healthcare CEOs ask me how do we retain our staff, right? And part of me just wants to say you don’t, ’cause you suck and they should go do what they’re passionate about because it’s not this. But that’s not really the answer. The answer is, wait, no, so they are passionate about physical therapy. They are passionate about… I had a person at a meditation retreat I went to who’s a physical therapist, and all of her department quit. She’s the only person left and is just working triple X, but she’s passionate about it. But she’s burning out, that’s why she was at the retreat. So how do you think about this?

– [Peter] No, and I’m dealing with it.

– [Zubin] This walk in your shoes type of thing.

– [Peter] Yeah, totally, and I’m dealing with it now. I mean we’re dealing with it, that most healthcare organizations have 20% vacancy rates right now. Because people are saying I’d rather not work than keep doing it at this pace.

– [Zubin] Right.

– [Peter] Right?

– [Peter] And to your point, the people that stay, the other nurses and frontline people that stay, their reward is now get to do double the work.

– [Zubin] Double the work, yeah.

– [Peter] Now you get to pick up everybody else’s slack.

– [Zubin] Yeah.

– [Peter] And that’s not fair to them.

– [Zubin] Right.

– [Peter] I think for us, what we need to make sure that we do is value those people well. When I say value I mean make sure they’re being paid appropriately. Make sure they’re being trained appropriately because to your point, we’ve got a lot of float nurses and ICs and locums that come in, and they do… And I don’t want to slam them, because we have great ones, but they may not be trained to do all the things that you need them to do.

– [Zubin] Correct.

– [Peter] Right? And so if you don’t onboard them and train them well, then somebody else by default ends up doing some of that work.

– [Zubin] Yeah yeah.

– [Peter] So we oughta be able to pay them well, we gotta be able to train them well, and we gotta be able to find, at least partner with our physicians and clinicians and others to say what are some things that we can all agree to streamline together. Because half the battle is the variation that people deal with on a day-to-day basis. A nurse could be working with one doctor one day, and I’m sure you nurse out there will understand this, and know that this person likes it just this way. And they work with another doctor the next day and it is totally different.

– [Zubin] Totally different, yeah.

– [Peter] And I think that as a department or as a care center or whatever setting you’re in, if you can come to some baseline agreements on how you’re all gonna agree to do a little bit of it together, it helps at least smooth out some of this for those people that are just coming on to help out, and who may not be as experienced as others to do what’s right. Does that make sense?

– [Zubin] Yeah, it’s a real challenge and it’s multifocal, right? But how do you make people feel valued?

– [Peter] Yeah.

– [Zubin] As a leader.

– [Peter] Yeah, that’s the million dollar question, right? Is that value component.

– [Zubin] Yeah.

– [Peter] One of the things I love to read is Seligman’s, he’s a psychologist that’s written a lot about flourish and doing well. And what he talks about is that, it’s like Maslow’s Pyramid, right? Everybody has the same core things that they want. But Seligman I really appreciate because he talks about performance at work. And he says when people go to work, they want to have a couple of things that they feel. Number one is positive emotions. They want to actually look forward to going to work.

– [Zubin] Right.

– [Peter] Right?

– [Peter] They want to have relationships. They want to feel like they’re part of a team and they like the people around them. They want a sense of meaning. They want to feel like what they’re doing is really something meaningful. And the last part they want is a sense of accomplishment or achievement. They want to end the day and go man, I helped five people today, and I really think that I changed the direction of this patient’s outcomes in my own way. And I think that if we can really start tapping into making people feel those aspects at work, it will help change the dialogue and the discussion around how people work and how long they stay.

– [Zubin] This is great, I took notes on this because I’m speaking for a large physician group tomorrow, and I’m gonna mention some of these things because if you give people the tools, meaning technology, the resources, meaning team, and the autonomy, meaning the freedom to make decisions within the purview of their training, they will start to have more likelihood of having positive emotions, deeper relationships, a sense of meaning and a sense of accomplishment.

– [Peter] Yup.

– [Zubin] My best days as a hospitalist were always that thing. Oh my gosh, the whole team’s firing on all cylinders. I have this great resident, the social worker crushed it today, case manager got–

– [Peter] Someone brought donuts.

– [Zubin] Someone brought donuts! The nurse was on fire, was really nice. Everything was beautiful. And then the patient said thank you and they felt really connected. They said something beautiful that made me feel like there was a meaning to my life and I felt accomplished because I got all the patients what they needed. I felt like I have the tools and the resources and autonomy to do it. And those are the best days.

– [Peter] Yeah. Yeah.

– [Zubin] The worst days are where every single one of those things is firing a blank. That can happen. The team is dysfunctional because we’re all burned out and unhappy and we’re blaming each other, the relationships are falling apart.

– [Peter] Someone calls in sick.

– [Zubin] Someone calls in sick and you know, you’re like I know that guys on the beach right now because he just needs a mental health day.

– [Peter] Yeah, I just saw him on Instagram.

– [Zubin] Yeah, I saw him on Instagram like hey yo with the duck face and all that.

– [Peter] Check out my Woo Girl!

– [Zubin] Woo Girl! What up! Yo! ZDoggMD! Hey fam, how y’all doing?

– [Peter] Fourth bottle!

– [Zubin] Everybody in the hospital just fighting that COVID! It’s like come on, dude. I hear from people that are quitting, and they tell me, you can just check these boxes negative. You know? So as a leader and a clinician, this is where that opportunity and that challenge is.

– [Peter] Definitely. And I think you hit on the autonomy part which is something that we take for granted. People want to be able to do what they need to do at the frontline in a way that helps them and the patients, right? My philosophy and my mantra has always been when we put in a process or something into the care center, number one, it has to be good for the patient. Number two, it has to be good for the providers and caregivers. And number three, it has to be done effectively and efficiently. If it doesn’t meet those criteria, then we’re just gonna spin our wheels and we’re gonna put something in place that’s gonna drag people down. And I think as a leader, as leader of a medical group, and for other executives out there, one of the most humbling things for us to understand is we’re too far removed from some of those things that matter to patients, and we should allow those people to be able to make decisions on how to do it better.

– [Zubin] Yeah, yeah, yeah, yeah. Really people who know best.

– [Peter] You mentioned the chapter on leadership and management. The things that they have, a lot of studies that talk about how decisions are made in large organizations. And what they find is number one, when you have a very large bureaucratic organization several things happen. Number one, as much as a third of the overall cost go to that layer of management and bureaucracy.

– [Zubin] 30%, yeah.

– [Peter] Number two, you’ve got people that are too far removed from a decision to really understand it.

– [Zubin] Yup.

– [Peter] Number three, you’ve usually got somebody that’s such a high executive-level person that everyone’s afraid to question them.

– [Zubin] Yeah.

– [Peter] Their decision.

– [Zubin] Yeah.

– [Peter] And then number four, which is the most painful, you probably have to go through four or five layers of approval.

– [Zubin] Yeah.

– [Peter] I mean I’ve worked in organizations where they did capital planning which you have to be very careful with capital planning. But if you wanted something, a building or a facility or something raised, you had to submit it a year and a half ahead of time.

– [Zubin] Yeah, of course.

– [Peter] And hope that it was gonna eventually get approved and addressed, right?

– [Zubin] Yeah, so the bureaucratic layers that you have to go, I know that even when I speak for an organization, it has to go through multiple layers of meetings and approvals. “Well is ZDogg too much of a loose cannon? “Is he gonna say anything about this? “Because we don’t want that.”

– [Peter] We have this committee that approves dollar amounts up to this. If it gets above this dollar amount, then it goes to this committee. If it gets above this dollar amount, then it goes to this committee.

– [Zubin] Exactly, and as someone with infinite speaking fees, they approach the asymptote of infinity.

– [Peter] Is that right?

– [Zubin] Imagine the committees I have to go through. I have to go through the president of the US. Biden has to stamp off any talk I do for like the local rotary club.

– [Peter] Yeah, that’s how it goes.

– [Zubin] It needs…

– [Peter] I think that we have some leadership opportunities to help empower the people that are taking care of our patients in a different way.

– [Zubin] Talk to me about electronic health records because there’s a chapter on that, man, this is good.

– [Peter] Oh my goodness.

– [Zubin] This is like everything we’ve been talking about for so many years and you put it in one book.

– [Zubin] It’s great.

– [Peter] Yeah!

– [Peter] Electronic health records. I can say statistically, electronic health records are one of the biggest factors in contributing to people having moral injury and not wanting to practice anymore.

– [Zubin] Yeah.

– [Peter] I think you described EMRs the best when you call them glorified cash registers. I think that that the EMR was made to capture a lot of things, but not necessarily to take care of the patient or those providing that care. I’ve got actually one comic in there where I talk about Dr. Katz who’s talking to another doctor. He’s like “Look, man, I’m spending all my evenings “just charting in the electronic medical records.” And the other doc’s like, “Yeah, those EMRs can be tough.” And he goes, “I used to think,” and I quoted you, I said, “I used to think EMRs “were just glorified cash registers, “but now I know why they’re called EMRs.” And he says, “Why is that?” He goes, “Because they lead to early mandatory retirement.”

– [Zubin] I saw that comic, it’s great.

– [Peter] And it’s true. And I have to give… Dr. Jane Sy is one of our docs and she actually talked to me about this. She said one of my docs says that the EMR is gonna lead to early mandatory retirement.

– [Zubin] Totally. I’ve had many docs tell me that.

– [Peter] And there are studies that show that statistically, that physicians are more likely to shorten their careers if they’re a little bit older and towards the end when they say it’s just not worth it. And it’s because of EHRs.

– [Zubin] And you know what? We talked earlier about leadership being disconnected from decision-making, from frontline decisions so they’re so far removed. They can be, right? Imagine what the epic engineers are like.

– [Peter] God.

– [Zubin] Right? Or any of these big EHRs, Cerner, athena, any of them. They’re so disconnected from that frontline clinician even though they have like a token doc or two on the staff, they have no idea. And I’ve talked to some of these guys and it’s not good. They’re condescending the doctors, they feel like they know the right answer. It’s like you don’t take care of the patients anymore.

– [Peter] Yeah.

– [Zubin] Right?

– [Peter] Well, and they compound the factor by saying, “Listen, this is our EMR. “We’re not gonna open it up to anybody else.”

– [Zubin] Right, exactly. It’s a closed garden.

– [Peter] We’re not gonna be interoperable to anyone else.

– [Zubin] Walled garden.

– [Peter] So whatever data you have, scan it in, make sure that they scan it in. We’ll put it into a miscellaneous file where no one else will find it because docs are too busy to say where am I gonna find the last admission from this patient that was outside of this epic EMR, right?

– [Zubin] And how much does that… Patients don’t realize this. The lack of the duplication and the lack of accessibility of EHRs drives up cost, number one, ’cause you redo procedures.

– [Peter] Yeah, I don’t have your lab, so I’m gonna go ahead and do them again.

– [Zubin] I’m gonna go ahead and do them again ’cause I don’t want to get sued, which we’re gonna talk about.

– [Peter] Yup.

– [Zubin] Or worse yet, I’m gonna do a procedure that was already done, because you don’t really know what was done, and it was some other outside place. And then you get a complication from the procedure or from the diagnostic, or an iatrogenic problem that we caused. Well that contributes to the medical error problem.

– [Peter] Yeah.

– [Zubin] Right?

– [Zubin] So this is a solvable issue. It requires political will, it requires technological prowess and it requires some degree of motivation. It seems like we don’t have those things colliding in a way that’s gonna make it work.

– [Peter] Yeah. Well, and even more so. I mean you look at physicians and clinicians spending 50% of their time seeing patients. The other 50% just charting.

– [Zubin] Charting.

– [Peter] I mean come on.

– [Zubin] So we talk about best days, worst days. My best days were when the residents wrote my notes for me. That was it. When that went away and I had to write longer and longer notes, and Medicare rules and stuff changed, and I couldn’t just sign off on resident notes. And they were doing less and less ’cause they had work hour rules, then it became a job that became instantly harder and the thing was now I couldn’t spend as much time with the patient in the room as a hospitalist. I used to spend an hour with the patient sitting there at the bedside, holding the hand, going through everything. ‘Cause I like to teach, so oh, here’s my chance to really educate this person so they don’t come back. And then it was like a U-turn at the bed and go chart all the things that I should’ve talked about where I said hey, don’t smoke, don’t do this.

– [Peter] Yeah, yeah, yeah.

– [Zubin] Click, click, click, click. Mission accomplished.

– [Peter] Yep.

– [Zubin] It doesn’t work.

– [Peter] Yeah, well, and you lost that soul. And maybe I’m just older, but you lose the soul of what the note was, right? You used to be able to write a progress note that kinda gave a good story of the patient.

– [Zubin] Captured, yeah.

– [Peter] Now it’s so templated out. I only read the assessment and plan. I don’t even read the notes.

– [Zubin] The rest of it’s garbage!

– [Peter] I don’t read anything.

– [Zubin] It’s all boiler plate, copy/paste.

– [Peter] What’s the diagnosis and what did you give them? That’s it.

– [Zubin] And even those AMPs have been copied and pasted and copied and pasted into oblivion.

– [Peter] Yeah, yeah.

– [Zubin] And sometimes they even just pull in the diagnostic codes from the problem list, and then they just start scribbling underneath it and type. Part of the thing about writing notes too… So what I found is that there’s some cognitive connection with actually writing with your hand that allows you to understand the patient’s story better.

– [Peter] Well, and there’s studies that show that.

– When you write things down by hand, you remember them better and it actually helps you explain things in a different way.

– [Zubin] There you go.

– [Peter] There’s a lot of research behind that.

– [Zubin] It’s an organic human process. Now maybe the next generation that’s raised entirely on computers will be different, but until then, we’re still with this. So what I used to do is I would talk, say you’re my patient, I’d be like “Hey Peter, so tell me what’s going on. “So you had chest pain for how long, and how long,” and I’d be writing it down, writing it. I take some little notes, I’d doodle a little doodle because sometimes I get bored with a 90 year old telling me their life story and they have mild dementia.

– [Peter] Yeah, yeah.

– [Zubin] But in the end then what I would do is like, okay, I know what to do for this patient. Then I would just go okay, blah, blah, blah. Type type type type type. That would take another 10 minutes of typing, that was a total waste of time.

– [Peter] Yup.

– [Zubin] And if there was a way that just the computer could translate my scribble into a note, wouldn’t that be great?

– [Peter] Yeah, and I agree. And again, there’s resources out there nowadays. Well there’s scribes. Scribes have been around for a while, and they’ve been proven to pay for themselves when done the right way.

– [Zubin] When done correctly.

– But there’s AI and there’s other types of things that you can actually talk to the patient that can capture a lot of this for you.

– [Zubin] Yeah.

– [Peter] We need to get back to the essence of taking care of our patients the way we’ve had in the past, but also in a quality manner.

– [Zubin] Right, and that that’s the heart of Health 3.0 is technology that enables the human relationship. A payment model that enables us to just do the right thing for patients and we get paid. Just do whatever’s the right thing, and give us the tools, resources, and autonomy to do that.

– [Peter] Yeah.

– [Zubin] Make it a relationship-based care model, not just with patients, but with each other so that we feel accountable to each other. That’s key. Without accountability, that’s why I think the distinction between often the isolated, private practice doc who isn’t in a group or isn’t… It can be very tricky, because there’s no… You can just do anything you like.

– [Peter] Yeah.

– [Zubin] And it becomes a really isolating and siloed kind of way to be. As opposed to say the opposite extreme where you’re in a group where everybody’s rigid and you have to have these checklists and so on, then you lose autonomy there. So there’s a balance between them, yeah.

– [Peter] That’s so true.

– [Zubin] How’s your thinking on… You have a chapter on basically malpractice. “The Best Offense is a Good Defense.” Tell me about that.

– [Peter] Well I mean, I don’t know, Zubin, I don’t know if it makes you uncomfortable, but I don’t know if you’ve ever been sued. I can tell you that I’ve been named in a lawsuit twice.

– [Zubin] Yeah. It’s common. Most doctors, right?

– [Peter] Over 50% of physicians 50 and older have been in a lawsuit, involved in a lawsuit. And I think that all of us have that beneficence, we want to take care of our patients. We wanna do the right thing. The last thing we wanna do is harm a patient. But there’s nothing more traumatizing to clinicians than to be involved in a lawsuit.

– [Zubin] Absolutely.

– [Peter] Number one, to your point, you feel very guilty because the outcomes weren’t necessarily what you thought.

– [Zubin] Yep.

– [Peter] But number two, it is an emotional interrogation for you. It is questions and depositions, and time-consuming and all these other aspects away from work to deal with something like this. And then when you look at the statistics, over 65, 70% of lawsuits end with no fault, right? And what we’re challenged with now is that the fear of litigation, depending on what state you’re in, they could come after your malpractice insurance, and whatever’s not covered ends up being owed by you.

– [Zubin] Right.

– [Peter] Yeah, right? So that fear actually makes people start practicing in different ways. And I talk about positive defensive medicine, and I talk about negative defensive medicine in my book. Positive defensive medicine is like you come in and you say hey look, doc, you know, I’m not feeling well and it’s just my throat’s been hurting, it’s been going on for a few weeks. And I’m not sure what it is. And I’m really worried because my uncle had thyroid cancer and so-and-so had this, and I’d really like you to do X, Y, and Z. And you examine the patient, you go you know, kinda feels, I feel a lymph node, a little swollen, but I see your throat’s a little red, it might be a little pharyngitis, we could try to do this. And they say well, no, I’d really like you to work me up. I want the full gamut. So positive defensive medicine is me saying I don’t think you have this, but I’m gonna order everything under the sun, and let’s go ahead and get a thyroid ultrasound and everything else for you. Right? That is me saying I want to make sure there’s nothing that’s going to be litigious out of this even though my gut tells me…

– [Zubin] It’s okay.

– [Peter] There’s a 99% chance that you do not have what you’re worried about.

– [Zubin] Yeah.

– [Peter] Now negative defensive medicine is when you’re practicing somewhere. And you know, there’s studies around inner cities and others and you’re taking care of a patient who needs some care. But you’re worried that they’re not gonna follow through with it. So you don’t even initiate the care. You say I am not gonna do this surgical case because the risk factors for this patient are too high and I don’t wanna get sued, so I’m just gonna refer them to the county hospital and let them deal with this patient because I don’t want some negative outcome to come out.

– [Zubin] Right, and my quality metrics will suffer.

– [Peter] You hit it on the head.

– [Zubin] Especially for surgeons, yeah.

– [Peter] And I mentioned quality metrics. That’s in the chapter as well around how people avoid certain patients because they don’t want to be impacted from a quality perspective, but from a litigious perspective.

– [Zubin] Yeah.

– [Peter] And we have some states that have no caps on, you know, the non-monetary aspects, the medical aspects, the behavioral aspects of patients outcomes, right?

– [Zubin] Yeah.

– [Peter] And we need to find ways to be able to make sure that we reward patients for what they’ve gone through, but also understanding pain and suffering is one of those kinda gray things that can be very broad.

– [Zubin] Yeah.

– [Peter] And that’s a big misnomer for some people.

– [Zubin] Yeah, no, it’s a huge problem and I think patients also don’t understand, again, you’re either gonna get the whole gamut of things that you don’t need and could cause harm actually as positive defensive medicine, which I’ve never actually heard the distinction, this is really interesting, and negative defensive medicine while I’m just not, I’m not going to do that surgery on you because you’re so high risk. Whereas someone at a county who doesn’t have say that negative aversion would do the surgery knowing and give you the disclosure that it’s gonna be high risk and would do it. Yeah.

– [Peter] Yeah, when you think about lawsuits and you think about the rewards for those people that win a lawsuit, where does most of that money go?

– [Zubin] To the lawyers.

– [Peter] That’s right. Some states have been actually very having have a lot of foresight in saying we’re gonna cap the percentage that the attorney fee can be. Other states have not. And lorries have gotten as much as 50% of the reward.

– [Zubin] Yeah.

– [Peter] And, you know, California has actually got something coming up next year where they’re looking, there’s attorneys that are lobbying to eliminate the cap on attorney rewards.

– [Zubin] Oh Lord.

– [Peter] And so that actually, there’s a lot of studies around states that don’t have caps on what the attorney fee gets or their attorney reward gets, have much higher lawsuits than others. And so that’s something else.

– [Zubin] It drives up costs across the board too. And this is the thing, we do need to hold mistakes accountable.

– [Peter] I agree completely and I say that in my book.

– [Zubin] And you say it in the book, but one of the things that I’ve noticed is that you have to be transparent with patients. If you try to hide something, or you don’t apologize, or if there’s a mistake, you don’t own it and talk about it with the patient, you’re much more likely to get sued.

– [Peter] Yeah.

– [Zubin] And so there’s always gonna be that.

– [Peter] And some places have, they’ve instituted candor training around that. If a mistake was made you actually let the patient and their family know.

– [Zubin] Yeah, yeah.

– [Peter] And you have to acknowledge that.

– [Zubin] And that, you asked have I been sued, and the answer is no, but I have made mistakes and I’ve had to basically go in front of families and say, you know, I made this mistake that really harmed your loved one. And that is extremely hard, but it is much, much, much less hard than getting sued and then going into court and having to defend yourself because then you start to, the inner shame is still there.

– [Peter] Yeah.

– [Zubin] But the outer defenses then create a cognitive dissonance where you just wanna say I made a mistake. I’ve learned from it. I’m so sorry. Yeah.

– [Peter] I think one of the biggest things, one of the biggest gaps we have in healthcare is that we don’t share mistakes. And when you look at healthcare organizations, when you look at M&Ms, you know, we’ve all been in those situations in hospitals where something ended up, terrible outcome, right?

– [Zubin] Right.

– [Peter] And we sit in those morbidity and mortality rounds, and they talk about the case, but it’s non-discoverable. It’s under peer review. And once you leave the room, you can’t discuss it.

– [Zubin] Right.

– [Peter] If you could have all the hospital organizations get together and say what were the five major negative outcomes you had in your hospital this year.

– [Zubin] Yeah.

– [Peter] And what did you learn from them, and you allow the other hospitals to share their mistakes, where people go, oh, we did the same thing.

– [Zubin] Think how much improvement you’d have.

– [Peter] We could do that, but we’re so afraid of litigation, we’re so afraid of other aspects of risk, that everything is something that’s kept under close guard.

– [Zubin] I had a crazy idea just now, and I think it would be crazy, but what if you let families into M&M?

– [Peter] Yeah.

– [Zubin] Wouldn’t that be something?

– [Peter] I think it would be great.

– [Zubin] It would be amazing. ‘Cause they would feel they would go on the journey and be closer to closure. Whether or not there’s litigation. Now a lawyer would say probably that’s a terrible idea because you know, X, Y, and Z, but man, you know–

– [Peter] Because they’re lawyers.

– [Zubin] Because they’re lawyers. And the rest of us are humans.

– [Peter] Yeah, and we want people to know that. I mean remember the time when you were in the ER and there was somebody passing, you’d let the patient actually, the family actually watched while you were trying to take care of the patient.

– [Zubin] Right, right, right.

– [Peter] And now there’s a lot of fear around these things.

– [Zubin] Yeah, yeah. Now I want to wrap up by, ’cause we’ve gone through a lot of your book and we haven’t even scratched the surface of this thing. I think people should buy the book, we’re gonna give links, but I wanna about you because you’re the son of Mexican immigrants?

– [Peter] That’s right. So my family was, they’ve been in Texas since Texas was Mexico.

– [Zubin] You’re kidding.

– [Peter] Yeah.

– [Zubin] So old school.

– [Peter] Very old school.

– [Zubin] Like pre-Alamo days.

– [Peter] You could say that.

– [Zubin] That’s awesome. Which part of Texas?

– [Peter] West Texas.

– [Zubin] West where?

– [Peter] So I grew up in Fort Stockton, but I was born in Odessa, Texas.

– [Zubin] Odessa, yeah.

– [Peter] When I say Odessa people just know it for home of Friday Night Lights.

– [Zubin] That’s right. I’ve been out to Lubbock. Gave a talk out there. Yeah, I love me some West Texas. A little dusty out there.

– [Peter] Pretty much so.

– [Zubin] Yeah.

– [Peter] My wife’s trying not to laugh on the side over here.

– [Zubin] And how did you learn to draw like you do in this book? You did the cover art too. Look at this cover art, you guys. This is like Sisyphus pushing the rock. And in this rock, this is so clever by the way, in this rock or all the things that we struggle in in healthcare: productivity surveys, in-basket, electronic health records, meetings, management, time, regulations, prior auth staffing, leadership, denials interruptions, coding, resources, charting. It’s giving me chest pain, dog! Rules, bureaucracy, autonomy, meaning. Patient satisfaction. Autonomy’s here twice.

– [Peter] Yeah, there’s a few of them.

– [Zubin] Dude.

– [Peter] Lions and tigers and bears.

– [Zubin] Oh my! How did you get this–

– [Peter] You know, I’ve always loved to draw since I was a kid. I think all of us loved drawing when we were kids, right? But you reach a certain age where people will, your drawing sucks, yours is pretty good.

– [Peter] Keep doing it right?

– [Zubin] Yup yup.

– [Peter] But I’ve always drawn. I had an older brother, Danny, who was a big artist and he inspired me. And it’s funny. Every time people ask me about my drawing I’m looking over at my wife because I used to always want to be an architect.

– [Zubin] Yeah. My wife wanted to too.

– [Peter] Yeah, I just love drawing houses and designing houses. Of course my mind thought different, so the houses I made were triangles and circles and obelisks, they’re just odd-shaped different look houses. I remember when Vivian and I were dating, I was like my architecture drawing draft board was something I didn’t share with much, but I was like, you know, we’re getting pretty serious. Maybe I should show her some of my stuff and let her know.

– [Zubin] Did you make fun of him? Oh my god.

– [Peter] Dude, I showed her my artwork. And she’s looking at it, she’s totally quiet, and she’s going through and going through. And I’m waiting for that positive affirmation, right? And she’s like, you know, I think it’s a great idea that you went into medicine.

– [Peter] I was crushed.

– [Zubin] devastated.

– [Peter] She totally kept it.

– [Zubin] You married the right person.

– [Peter] I did.

– [Zubin] Because my wife did the same thing. I used to play guitar and I played guitar for her early on and she’s like, whatever, dude. I’ve heard people play better guitar than this. I was like, but my dreams of being a rock star!

– [Peter] Yeah, we’ve been married 22 Years. It’s funny, I mentioned my knee surgery. Last week I had arthroscopic knee surgery and a few nights before that I had this dream that the surgery went bad and the joint got infected and they’re gonna have to go clean it up. And that next morning I told my wife, I was like I didn’t sleep worth a crap because you know, I was thinking about the surgery and it went bad. I was waiting for her to say I’m so sorry. That must’ve been really tough on you. She’s like “What? “Are you gonna be a big punk about this?” She’s like “You need to cowboy up. “This is a regular routine surgery. “Nothing’s gonna happen to you.”

– [Zubin] Dude. You married so above your pay grade.

– [Peter] I was like thank you.

– [Zubin] Thank you. Guys need that! We’re the biggest wusses. When you got your second dose of vaccine I bet you were like ooh, oh it hurts.

– [Peter] My arm’s heavy!

– [Zubin] My arm’s heavy. I got a fever. And she was like shut up! That’s awesome. Did you wanna say hi?

– [Vivian] Oh I’m fine.

– [Zubin] She’s like hell no. Dude, yeah, you married well.

– [Peter] Well thanks.

– [Zubin] Yeah, yeah, and I mean what I love about this and that’s how we initially connected is that, and look, I’m even an endorsement on the back.

– [Peter] You are, you’re my number one at the top.

– [Zubin] I love it, dude! I was like whoever Eric Wall is, suck it dude! I took your number one spot. This is a manifestation of your authentic being. This is who you are. You’ve combined your clinical stuff, your leadership stuff, your MBA so you can learn all the words, and your art and your drive to make the world better into a thing. This is authentically you. If more people in healthcare allowed their authenticity to shine, despite the risk because you got risks.

– [Peter] I took all to of heat.

– [Zubin] You took heat and we’ll be better off, right? I’m better off having talked to you here. I’ve learned more about stuff that I think about all the time because you’re seeing it from a different angle. You’re seeing it not just from leadership, but as somebody who’s trying to artistically express it. So I really want to thank you, man.

– [Peter] Well thanks, Zubin.

– [Zubin] I think this is awesome. You’re gonna inspire people.

– I appreciate you having me on, and thanks for allowing us to sip some bubbles along the way.

– I’m gonna science the crap out of this a little bit more. Man, you know. This is, even though the bubbles have evaporated since we’ve been talking, that is just really good.

– [Peter] Yeah.

– [Zubin] It has those notes of chocolate. And on the description, there’s chocolate in the description which is interesting. So I wonder if I was incepted, but I think I actually–

– [Peter] You knew it. I’m telling you, it’s a sommelier thing before you said what you said earlier, you’re a sommelier.

– Dude, I’m telling you,

– [Peter] Were you really?

– [Zubin] In this life I’m too broke to be a wine snob. I get the two buck chuck and I’m like this is delightful.

– [Peter] Can’t go wrong.

– [Zubin] 100% tannins?

– [Peter] Yeah.

– [Zubin] Is that a thing?

– [Peter] Love it.

– [Zubin] 100% acidity And 95% tannis? That adds up to 195%.

– [Peter] There you go.

– [Zubin] Man, what a joy, and your wife is wonderful, you’re a very lucky man, and I think people who work with you are lucky to have you and we’re lucky to have you on the show. Guys. Links to the book Doc-Related, links to his website. Links to the wine. Woo Girl!

– [Peter] Woo Girl.

– [Zubin] That is great! Will be in the show notes. If you like what we do, you can support our show ’cause we don’t really have big corporate sponsors. We’re not like Joe Rogan where I’m like you know, this penis enlargement device that I’ve been using is just on point. I’ve gotten three or four microns.

– [Peter] I love that, microns.

– [Zubin] Microns. I measure it in statistically significant numbers like microns. Become a supporter of our shows, ZDoggMD.com/supporters. My favorite platform is Locals. ZDoggMD.locals.com because they don’t take a big chunk of your money and it’s this beautiful group that interacts with each other. You’re on Locals as well.

– [Peter] I am, love it.

– [Zubin] Yeah, it’s really great. It’s like people put their own comment. Peter puts his strips up there, people get to weigh in. It’s really fantastic.

– [Peter] Comic strips.

– [Zubin] Oh! Thank you for the clarification. Spoken like a true administrator.

– [Peter] Yes, yes.

– [Zubin] “I want to clarify very clearly.”

– [Peter] In no way remotely. Revealing anything.

– [Zubin] There’s zero stripping, 100% comic stripping. And also stripping. So thank you guys, share the show. And Peter, thanks a million.

– [Peter] Hey, thanks a lot, Z. Appreciate it, man.

– [Zubin] We are out. Peace.