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Imagine bringing back the joy and purpose and connection that we felt when we first decided to walk down the path of caring for others.
Dr. Kevin Ban and I sat down to discuss just how this might happen with the emergence of Health 3.0, and how technology might help for once instead of hinder us. Believe it or not, we’re at a tipping point.
Dr. Ban is an emergency physician, former longtime Harvard faculty, and current chief medical officer of Athena Health. In our wide-ranging discussion we talk burnout (aka moral injury), physician “capability,” the promise and the peril of electronic medical records, making mistakes in medicine and how they relate to communication failures, the “Doc Vader Index” or DVI, the horrors of becoming an administrator, and much much more. FULL TRANSCRIPT BELOW!
ZPac, check out the original video here on Facebook and let me know what your vision of Health 3.0 is!
– All right, ZPac, well I am very excited today, because I am the Chief Medical Officer of Athena Health, but none of that matters.
– At all.
– At all. He’s an emergency physician. His name is Kevin Ban. I call him Bon, it’s actually pronounced Ban.
– I like the Bon.
– [Host] It’s Bon because you’re a Hungarian Jew by descent.
– In fact, the name comes from my grandfather, whose last name was Bergel, but when he came across the United States he took the name Bon, which was actually his pen name.
– [Host] He’s a writer?
– In Hungary. He was a writer. So, it should be pronounced Bon, we’re in America so it’s Ban. But it really should be Bergel. So it’s a really complicated story.
– Ban, Bon, Bergel, potato, tomato, nuclear reactor. They’re all on the spectrum.
– [Kevin] It’s all good. I’m good today.
– Man, what a pleasure to have you here. So, there’s a reason that you’re here. Number one, you’re in Vegas, and I was like, “Come be on the show.” But number next, as we say when we dictate, you’re an emergency physician at Harvard for many years, now Chief Medical Officer of Athena, and you are really interested in this idea that many people call burnout, I am now starting to call moral injury, among physicians, and how we might be able to address it. Because both of us have been in that ringer, and actually, you’ve been all around the world doing it, actually, which we’ll get to later, but this idea that the front lines of primary care happening in the emergency department, and that technology can either make that easier or harder, and that all these regulations and all these rules that we have to satisfy, to just do what we went into this to do, which is connect with fellow human beings. It just makes it an impossible task and then we burn out, which is really, we have this moral injury, ’cause we’re not able to do the right thing for the patient.
– Yeah, and a really complicated system, where it happens day in and day out, where you’re trying to do the right thing but you’re overwhelmed by the system. I think when I was training back in early 2000s, there were about 80 million emergency department visits per year. Now there’re like 140 million, and this is not just about the ED, this is about everyone who’s impacted by that. The inpatient side, the specialists, the surgeons, everyone.
– Dude, we thought it was busy back then. ‘Cause I trained at the same time you did.
– [Kevin] Oh yeah.
– We thought it was busy then. We started instituting caps. We were the one year before the caps went in where you had to, and we were like, “This is unsustainable.” Now it’s vastly unsustainable.
– [Kevin] Worse. I was talking to a buddy over the weekend, a guy who I trained with. He’s the Director of a community emergency department in Massachusetts. I believe it might have the highest volume in the State. They see over 100,000 patients every year, okay. He’s got, like, 60 beds, and last week when he was working clinically, he went in to do an overnight and there were 70 boarders. So 70 people waiting for a bed, plus he’s trying to run 60 rooms. Imagine that day in and day out, and all the paper cuts. I like the way you frame it, moral injury, and I’m kinda familiar with that term. Because it’s a complicated problem, and I know I’m here, Chief Medical Officer at Athena Health, and we have to think about the electronic health record and the role it plays, but it’s much more complex than that. You can fix the EMR problem tomorrow, and you wouldn’t fix the problem with burnout.
– You know, you nailed it. The EMR is just a symptom, because, what the EMR is doing is it’s complying with this already jacked-up system
– That’s it.
– and it’s helping us to comply with a jacked-up system but, we know that the system’s jacked-up, at least unconsciously, You know what’s interesting, I don’t think it’s a conscious knowledge anymore because people have been conditioned to just accept this matrix that we live in. They don’t see the matrix. You give them the red pill, like, for example, let them work in the kinda clinic we built Turntable Health or one of the Orris clinics or a direct primary care clinic, or a really advanced foreign hospital, something like that, and they will see, oh, you can actually just take care of patients, do the right thing for the patient and do well financially. That’s a big deal. Well then, the moral conflict is gone.
– Yes, and the feeling is completely different to those people because they’re really connected to the reason why they went into healthcare. Thinking right away, most of what you think about the electronic health records, most of what is soulsucking gut wrenching is the stuff around clicking these boxes and doing all this documentation for government programs or payer programs that don’t really correlate with care and with quality. Day in day out, is mind numbing to people. Take that away and all of a sudden they’re just thinking about the reason why they went into healthcare, and connecting with their patients, and it feels different.
– I like to think of it in terms of what was the best shift you had, or the best day you had. Remember back to that. What was happening? The system was down, I couldn’t chart, so I just have to talk to patients. I spend time with them, or I had fewer patients that day for some glitch in the matrix, and so I was able to sit and spend time, really connect with the team was there and they were learning and teaching eachother. Everybody was firing on all cylinders on this team and I felt deeply connected, not just to my patient, but to my colleagues, and to my purpose all at once, and I left energized, ready to work even harder. I got to thinking, they think we didn’t want to work.
– Right, that’s the paradox, is that it’s not that you necessarily want to work less. What’s interesting is that even 50% of physicians who say that they’re burned out, still feel fulfilled in terms of the interaction they’re having with patients. This is not about just wanting to check out and be done with it. It’s wanting to do the things that you think are high value and the things that matter to you. You asked me the question, reflect back on that shift. One of the things I did was, and I’m an early adopter. I’m one of those people. Give it to me. I’ll give it a shot. We started talking about scribes. I was one of the people like, give me a scribe. It was the best thing I ever did. I don’t know a provider who wants to have an electronic health record in their life. We have to figure out a way, and we can talk about this. To make the electronic health record be something that puts wind in the sails, and not something that prevents you from working. That scribe allowed me to do the stuff that I thought I should be doing as an academic doctor. Like what? Taking care of patients, and communicating with their families. Talking to the paramedics, teaching the residents.
– Wait, wait, wait, wait. You talk to the paramedics?
– Oh yeah, big time.
– Who are you man? Come on.
– I’m such an aberration.
– So many of our fans are paramedics, and they’re like, no one talks to us. No one listens to us. They don’t take us seriously. We do all this work.
– But it’s a real one. At Israel Deaconess in Boston, we had to work on that. Literally say as trauma patients were being brought in, allow the patient to die for 15 seconds. So that you can listen to the paramedics. We would not allow anyone to put hands on the patient, until report was taken. It’s that important. But one of the things that I learned, having the scribe, was that I was focusing now, on all the things I wanted to be doing, and I would end my shift feeling pretty fulfilled. There’s always good days and bad days, but I felt like I was doing the thing that I was there to do, and I didn’t have two hours of charting like I did every other shift before the scribe.
– Then a good parallel to that is old academic practice, like I used to have, where the residents would write the notes. You would just be present. Present for the team, present for the patient, present there.
– Agree with above.
– Agree with above. You can’t do it anymore. You can’t great days because you got to be present with the patient and form those connections. Yesterday, I did this rant for my show, where I was like, why the hell do we have this show? Why do we have this movement? What is the heart of it? The heart of it is love, and then you sound spooky, but what is love? It’s a connection between human beings. We’ve broken the connection. That’s why the scribe it sounds like allowed you to reconnect.
– Reconnect, yeah absolutely.
– Reconnect, yeah.
– I think that was apparent to everyone. I was seeing patients more safely. Teaching scores went up. Patient satisfaction. All these stuff comes together. I’m a big believer that we have to think about, resources and tools that can help us get there.
– This idea of tools and things, but before we go down that path, I wanna say one objection. People at Kaiser will say, we looked at scribes, and it didn’t make the doctors any more efficient.
– It doesn’t. Oh no, I get that 100%.
– Tell me about that.
– Well because what most people do when they’re busy seeing patients, is they continue to see patients, and they do the documentation later. I was finishing every shift, and I would try to get my charts done because that’s what I wanted to do, and I was spending two to sometimes three hours after my shift doing that. I wasn’t seeing less patients, I just wasn’t documenting during the visit, and so what happens then, in the alpha phase of that, when the department was paying for it, it was all good, because they were paying for it, and we were seeing what the deal was, but I wasn’t seeing more patients. They would say things like, you need to see maybe one or two more patients a shift, to justify the cost of the scribe, but I wasn’t seeing one to two more patients per shift because what I was doing was not documenting two and half hours after. What I was doing was connecting wholly during the shift, but I wasn’t doing more from an RVU, or a financial status. Does that make sense?
– But I chose anyway, to continue to pay for the scribe because I thought it was that powerful.
– All these things are little symptoms or little pieces of a potential solution, but what’s interesting is one thing you said which is now you’re present with the patient during the visit, and in emergency medicine, that’s crucial, because you’re looking at body language, you’re reading cues, you’re getting the smells and the sights and the sounds, and I remember doing this very clearly. If you have a chart open with you and you’re typing, and you’re talking to the patient, your mind is absolutely split. You cannot multitask. It is movement of attention back and forth, which means your attention is never focused. It’s always darting back and forth. To be able to solve that in my mind, you’d have to study it, but it seems to me like it would lead to better satisfaction, better outcomes, lower cost long run, even though you’re not seeing more patients. Do you agree, or do you think that’s crazy?
– No, I think that that’s right, but I don’t think that that’s how the system is set up right now. I was personally on a PNL system, so I needed to see a certain number of patients to justify my salary, and that in general cuts across all of the system, when we talk about fee for service. When you talk about moral injury, I like that concept, because this is a really complex problem and it’s multi factoral. Like I said, we’d get rid of electronic health record and we’d still have the problem. There are different things we need to do and part of that is thinking about the way in which healthcare works, and the system in which we’re working. I think value based care is trying to do that, it’s just going way too slow.
– It’s slow, yeah, and even the concept, we have all the catch phrases, value based care. What does it really mean? It means doing good for the patient, means doing well financially. That’s value, and meaning providing the best quality at the lowest cost with the best convenience and experience, that’s quality, but one factor that often is not in that, and that’s what I liked about, working with the folks at Athena. That’s the reason we’ve worked with you on music videos and things like that in the past, is that you guys actually care about the physician and the nurses and the frontline staff, because you were founded by someone who was a paramedic. This idea that there’s a fourth component which is staff satisfaction, caregiver satisfaction, and it’s not satisfaction sounds very trite, it’s our connection to our purpose and our patients. Is that being facilitated? You’re right, you could get rid of the technology and you would still have the problem, because we’re incentivized incorrectly. The value stuff isn’t here yet. We have this fragmented byzantine system that still has relics of the 20th century in terms of this cowboy autonomy, but is trying to homogenize everything in a new way that is also wrong. What has to transcend is this 3.0 vision.
– We’ve been working on this at Athena. Taken concepts from outside of healthcare, which is a good place to start maybe, and talked about capability. What does it take for a physician to feel capable? I don’t love the term, because for a physician if I say capable, a lot of times they’re thinking fund of knowledge. What am I capable? That’s not exactly what we mean by it. It really breaks down into three different things. We’re talking about, do you have the resources to get your job done? Do you have the tools to get the job done? Then the third piece of it is, do you have the latitude, and as you start to frame it like that, it gets interesting. All of a sudden it becomes actionable in a way and then we follow that up even with another survey we did across properties which is the beauty of.
– You guys own apocrates.
– We do yeah. Not only are we single instance, in terms of this network that AthenaNet that we’ve built but we also have Apocrates, where we connect with physicians.
– At one time is AthenaNet going to go sentient and destroy humanity. It sounds like it’s happening right now as we speak. This is 2018.
– I’m distracting you.
– I thought I smelled nuclear missiles launching.
– That’s us taking over.
– Congratulations man. You beat the AI. It does feel good to destroy humanity. Now getting back to the humanity piece, it’s interesting, because when you talk about capability, you’re talking about tools, resources, and latitude. Now latitude I consider, I use the word autonomy. You guys are big nerds.
– I like autonomy.
– Autonomy is good. It’s all semantics, but what’s interesting is you guys were studying this, and me and Jessica Sweeny did a show about this actually at your headquarters a while back because I was very compelled by this idea, and then I went back recently, and I was looking through my writing on my website about health 3.0 and I talk about health 1.0 this cottage industry. Health 2.0, the matrix we’re living in now, and health 3.0, and what I said, there was a line in there, and this was years ago that I wrote this, again, we reclaim the humanity and the repersonalization of medicine by having the tools, resources, and autonomy.
– Did you really write that?
– I actually wrote that to care for our patients. When I heard you were going to be in town I was like this connection means that the most brilliant mind in medicine thought of this already.
– That’s you.
– No, it’s actually Dr. Ross. It’s Dr. Ross, but this idea that these things converge. It’s not just business speak. It actually from people on the frontlines this is how it feels. If we had, let’s dig into a little, what do you mean by resources? Let’s take something like loneliness. Something that people are talking about more and more.
– We have Yvette Murphy on the show. Former Surgeon General talking about loneliness. It’s his passion project now.
– It’s a really big deal. People in California that are really interested in it. There are a lot of people interested in it, but if you’re a physician sitting in front of a patient, and you’re concerned that loneliness plays a part in this but you have no resources by which you can impact that, would you ask the question?
– No, I’ll tell you right now, a provider will never ask a question they don’t feel like they can act on. My example is, I started off, I matched in urology, and I did two years of general surgery and six months or urology.
– You gotta have a good sense of humor for urology.
– It’s great stuff.
– Did I ever tell you about the song I wanted to do.
– Urology based.
– Yeah, it was about I’m a rebel just for kicks now, but it was gonna be I’m a doctor just for now. I had to bleep it out, because it’s a family show.
– But it’s good. I like where you’re going with that.
– I’m glad you do.
– You might have a future in this.
– Momma says so.
– During my residency, it was right around the time viagra came out, and you would never have asked about erectile dysfunction before because there really wasn’t much to do about it, but now all of a sudden there’s this little pill, and we were like any more questions before we finish our visit, and then you bring up the topic, and you see them get interested, but you felt empowered because there was this resource, a medication, that could actually fix a problem, that’s a big problem.
– Funnily enough, now that you’re asking these questions, now we have an epidemic of nursing home syphilis and gonorrhea. You’re welcome.
– You have to be careful, because you can take this pill. It might cause a heart attack, but that’s a good way to die.
– That’s a good way to go out. It’s a good way to go out. But you’re right, yeah, go ahead.
– That whole concept of having to have the resources, whether it’s for loneliness. Transportation is a big deal. All these different things that are really now being called social determinants of health. I’m becoming wary of that.
– Tell me, tell me, because I use it a lot, and I feel a little bit weird about it, because it’s more than that. These are our patient’s lives. What are the social determinants of health. This is their life, and here’s the tiny piece of it that intersects us.
– I hope too that it’s not being used to say something to our patients about their.
– Social status. Racial status.
– That’s where I get a little bit concerned, where you should just say what it is but these are the social aspects that get in the way of us taking good care of our patients. I spend eight years in Italy on behalf of Harvard. Tough job.
– What a life. God you guys, ivory tower buttheads. Go to Italy.
– Live in Florence.
– Florence, my favorite city in the world, and you go and live there.
– I’m married to a woman from Florence. Both of my kids are born there. It’s more and more infuriating.
– I’m so angry right now.
– You’re fuming inside.
– If I were Bruce Banner, already green veins would be popping out.
– Doc Vader’s gonna pop out.
– Don’t let me forget to talk about the Doc Vader index.
– We have to talk, but what was interesting while I was there, was really appreciating how much emphasis they put on to the social aspects. It’s that 80%, 20%. We’ve gotta flip, where everything has to be medicalized, but really it’s social issues, and I think we’re gaining appreciation and like anything, you have to first step in solving your problem is saying hey, we got a problem. Let’s solve the problem.
– Can you imagine America going to a 12 step program? Hi, I’m America, and I’m a social determinant alcoholic. I have a sponsor. I believe in a higher power. His name is the Gozarian. No formal training. You were in media too. Didn’t you do some reporting?
– Going way back. In fact maybe I can teach you something about medical communications. That’s a joke.
– I’m not sure it is, because I want to see how would you start a show as a reporter. You did medical reporting in Boston, right? Do your voice.
– That’s not the only. This is my joke voice. I did medical reporting, you’re right. A couple years in New York City and then three years in Boston while I was doing my residency which was a fun thing to do. I brought in a little extra cash so that I could date my Italian.
– Basically the Anthony Bourdain minus the severe depression. That I can tell anyway. Tell me more about Italy. Tell me more about Italy.
– I think that was my humbling experience ultimately because we went there in our typical American Harvard way. We were making fun of things that they were doing and things that we now do, and I don’t think it sunk in immediately but I saw what it looked like to think about population health management to use the term. I came back from Italy after eight years, I was back and forth, and tried to make sense of that, and got closer and closer to population health management, which is actually how I got over to Athena, which was doing population management.
– Because you were working on that, Athena was like we’re trying to do better on that angle.
– Yeah, for me it was a great experience because I got outside of Boston. All of us are a victim to being.
– It’s a good idea to get out of it, so I’ve had pleasure of working with large organizations on the west coast, and small organizations in western North Carolina that do great work, who are actually executing on the stuff we’re talking about, but never really quite getting done.
– Interesting. Have you ever had to set up an east coast west coast rap battle, because I was just listening to California, knows how to party. Knows how to party with Dr. Dre and Tupac, and he said some really inflammatory things about the east coast.
– I’m still upset about that, and I feel like I want to act on that, but I don’t really know how to, so maybe you can help me with that.
– There’s a template. It’s a formula. That’s what I like about it. Back to population health. When you look at this now, here’s a question. When you went to Athena, and this is, I’m intellectually curious about this, did you start as Chief Medical Officer or did you have to stab your way to the top?
– No and No. I went to Athena, because I thought there was an opportunity to do something I was really interested in every day and so I went there to lead population health team. I was not the chief medical officer.
– But then you killed the chief medical officer and were able to slide in.
– We got into a rap battle. That didn’t happen either, but no one will believe that.
– A lot of doctors are looking to do other things, because of this they don’t feel capable in their job taking care of patients, so they’re like maybe I can fix the system. Are you hopeful that is doable? Working in a company, can you actually move the dial on making doctors feel like they have better resources, better tools, and better.
– Yeah, I think things have gotten significantly, the conversation has really moved along quite a bit. It kind of feels like we’re puttering along and maybe it’s just me being an optimist, but I feel like there’s an inflection point. There’s this Malcolm Gladwell’s Tipping Point that we’re going to hit. I think we have been struggling with all this government regulation. Obama years put a lot of regulation on and some of that was necessary and well intentioned but got sideways on us to a certain extent. I don’t think we’re gonna see a lot of that in the next couple of years, and it’s a good time for us to figure out what matters. I think that’s what we’re trying to do. There’s no widget that’s gonna fix your problem, so we’re trying the understand the problem. That’s why we’re doing this research around capability and trying to understand burnout, which is something we’ve got a bit closer to, and I’m hopeful that as leadership recognizes it as a problem, it’ll do something to impact it, and do something meaningful. I’m not talking about mindfulness, meditation, and I believe in all those things. I’m raised by a hippie freak who got us going on transcendental meditation. I think when I was nine years old. I do yoga.
– I’m with you brother.
– But I don’t think that’s gonna solve the problem, and I think that we have to understand that there are bunch of different elements and it starts with leadership and it starts with communication, real communication with folks on front line and then acting on those things in a way that makes their lives different. I would start there before the HR, although the HR is something we should focus on too.
– You said a lot of stuff I want to cheer for, one is tipping point, yes. We’re at a tipping point, and this is part of the reason we even do our show is that we’re sensing this tipping point and just on this Facebook channel there’s 1.1 million healthcare people.
– Yeah, I know, you’re famous. You’re already famous, back to you Bob. I’m Kevin Ban, should be pronounced Bon but also Bergel. No, but this idea that things have gotten so bad, and now we do, you’re right. There’s a regulatory gap now, where we know we’re not going to get new regulations for periods, so we can figure out what matters and then create a better way of doing things and whether that starting by fixing these ideas of moral injury through providing better resources. We have better support maybe. Better tools, better HR, better diagnostic software, better AI that informs us, and again these are catch phrases, better population health.
– I think what the matter is we’ve been dumping information into this electronic health record which is a glorified billing platform.
– You’re the chief medical officer of a major EMR company, and you just said it’s a glorified billing platform.
– That’s where it started. Let’s talk for a second, and say what if, it had not been about billing? What if it had been about trying to help doctors be more efficient, effective, productive, but what if it had been about taking better care of patients in such a way they were really connected and engaged and so were physicians and that would all result in better outcomes and physicians not being so burned out. What would it look like? It might look more like Amazon with apps and you could be like I like that app. I want this one, I want that one.
– The urology app.
– I want the app that listens to me while I’m in the room with my patient. That exists. That stuff is out there. We have that in our marketplace. You could choose that, and build something that would help you engage better with your patients, and drive better outcomes. That’s not what happened, but it might have looked like that, had that been the true North up front.
– Can we get there?
– It’s hard because now you’ve built something with all this legacy stuff behind it. We’ve got really talented smart people who are deeply committed to making healthcare better. Unbreaking healthcare. It’s a really cool concept, and there are times working on meaningful use certification when they’d rather be doing the things I just mentioned that will actually help you take better care of your patients. It’s hard when you start in a certain place and then you try to move it, but we have to move it, and I think we’re starting to see that. This is the time when interoperability, integration, might be possible. There are moments I feel like, that failed, we should rely on patients to do that. Should we be putting more power in the hands of the patient so they can do their job. Give them a thumb drive with all their information.
– Something even more tech savvy.
– We don’t use thumb drives anymore. I go to conferences. They give me thumb drives all the time.
– I think about the role of a patient, and how complicated and difficult it is. You know this. I get the call all the time, which is sometimes about healthcare or making a diagnosis or treatment but is more frequently about navigating an impossible system. If you are sick, if you have chronic medical problems in this country it’s a full time job, and if you have no tools. What if we did that? What if doctors got on board with engaging patients in that way? What would that look like?
– I think that’s the key way and that’s why I think clinical leadership matters. As a doctor, now you’re leading and you can actually make a difference and I think we’re missing that in a lot of aspects of the world. I got a call. I don’t know if I should talk about this, but I’m going to, because I no longer care. We are so out of the box.
– Not sure how I feel about this.
– You should feel very good, because this honesty is what people want to hear. I had a call with epic. Their PR people, because they were upset with me because of my rants and ravings about how the electronic medical record, and by the way, why am I not calling it a CHR? Was one of their complaints. Comprehensive health record. Well when you make comprehensive and health then I’ll call it that. Until then, I won’t. They felt like I wasn’t doing justice to the fact that there are good people working very hard to make it better and that they do involve doctors and they do involve clinicians. One of the things they said was, well we’ve built this Maslov’s pyramid and we’re spent all this time and energy and money building the bottom of the pyramid which is making the electronic chart do as much as what paper used to do. Now we’re at a point where we can create poetry and meaning and purpose and I’m like, I started using EHRs in the form of Epic in 2002.
– Is that right?
– Yeah, Palo Alto Medical Foundation. Stanford. I was there the night it went live, and it changed my life for good and bad. You started to see exactly, because we went from being able to look at our patients in the eye and our notes were short because we didn’t want to get writer’s cramp and now it was copy paste click. Copy paste click stare at computer, go home chart for three hours. Pajama time. I said it’s taken how many decades now to get the bottom of the pyramid but I don’t see that transcending until you blow up the bottom of the pyramid, and really do something unique. Maybe it’s a model where it’s apps. Maybe it’s a model where the whole incentive structure is changed. Because your question is one we should be asking. What if we had built it from the beginning instead of a billing and compliance platform, which has to be done. I don’t blame any company.
– That could have been an element of what it was about. But what if we had built it to be something different, where that was part of it.
– I love this idea of, there’s an app that will listen to you during the visit, transcribe it, and populate a chart note. Think about nursing. This is something we forget. I don’t think you forget it, because you deal with nurses.
– I’m still seeing patients, so I’ve decided to stay connected, and it informs this conversation for me still.
– Me too, so when I see patients at our county hospital, I’m watching the residents holding their iPads and click, click, click, click, click, clock, click, and sometimes they’ll say things like, well the patient says this, but in Epic it was documented this, so I’m going to believe Epic. You’re like Epic is shorthand for whatever EHR we’re using.
– Right exactly. This is not about Epic.
– No it’s not. It’s about, saying Pampers for diapers. I’m just saying the chart. A bandaid. In that setting, still seeing patients is crucial for physician leadership, because I think otherwise you definitely start to detach. One of the worst things that I had to do, we run Turntable Health without seeing patients in Turntable Health, and the reason.
– I think I made the assumption you were seeing patients.
– Not there. I would see patients in our hospital and if our patients ended up in the hospital, but the thing is, because we were partnered with Aurora, they hired the physicians. They were under their malpractice and this and this, and they wanted to keep it cohesive because then I would have to go to all the Aurora training sessions, and so they were like we don’t need you in the clinic and I was like but, but, but.
– Go to your office. You’re an administrator.
– You’re an administrator. That was one of the most hard.
– Now I think about when you did the Doc Vader with the administrator which is one of my favorite ones. You’re like that woman sitting there across the table.
– I am! I would meet with the docs, and I’d be like, the thing is, we need to basically get more patients here so we can make it sustainable, which means we’ll have to figure out and they will say here’s the issue. These patients have all different insurances, and we have homegrown EHR that doesn’t bill insurance and we’re out of network for this patient who is paying out of pocket but we’re in the work for this insurance company that’s paying our membership fee and it takes us all day to get through that. I thought we were supposed to be looking at patients in the eye. Okay we need to fix that. We need to narrow down our patient population. You narrow down the patient population, then what happens? You can’t fund the overhead. I would go to bed at night in a panic waking up in a cold sweat at two in the morning going this is going to fail and it did, and the biggest relief in my life was the day we finally closed, because I’m like I don’t have to be administrator. It was hard, and again, I’m acting like whoa is me. I have to be an administrator Kevin but the truth is I went from hating administrators and feeling they were the enemy to really feeling a deep compassion because they’re trying their best in a broken system.
– I agree with that wholeheartedly. When I came back from Italy I become chief medical officer in Israel, Deaconess medical system and one of the community hospitals. I found myself in a very similar situation that you’re in. A deep respect for people at frontline and what they were trying to do and feeling all the pressures of yeah we’ve gotta get that catheter out of the bladder. I was like can we not get a catheter out of a bladder or document why in the first 24 hours? Can that not happen? The answer is, that is such a complex issue. I felt very squeezed by that for sure. I think one of the things you said earlier is it matters that we have clinical people in leadership. We should not allow this new chapter, you’re calling it 3.0, this should not happen in the absence of people who take care of patients and understand what that means, being a big part of it. I think that there’s great hope, but it means people have to figure it out and it doesn’t need to be leaving and going to something altogether new and different. It could simply mean being sensitized believing this is the right thing to do and then trying to make some small change where you are. I actually like that quite a bit, and I become a lightning rod for people who think maybe they want to leave clinical practice, because they’re like Kevin did something different and my advice frequently is, the place where you are needs to have transformative change. Be a part of that.
– Start there. That’s what I tell the Zpac. Although now I’ve started to modify it by saying if you feel like there is absolutely powerless. Everything you’ve tried has failed. You’re running up against walls. Walk to a different system, because anyone who tells you you’re not employable is lying to you.
– I agree with that too. You try where you are.
– But you gotta try.
– Yeah, you gotta try, and the truth is that when I think about something like burnout in our survey, when we ask in the last 12 months, what percentage of hospital systems actually tried to do something. I think it was 72% of the hospitals or these systems had done nothing, and you feel like you’re in a place like that that is just not interested and just wants to churn and burn, then I understand, and then you’re going to need to move towards likeminded people, and be in a place where you feel like you can contribute, so I get that, but there’s the 28%. There’s the 28% of the hospitals that are trying to do something, and they need help getting it done. Be a part of that if you can.
– Yeah, absolutely, and the other thing is I think, we need to stop shaming clinicians who decide to go into these leadership roles. Have you noticed that’s a thing? You don’t see patients anymore. Actually, I do. I don’t see them all day every day, because if I did I wouldn’t be able to come up for air enough to do what I’m trying to do, and you need us in leadership. You need more of us in leadership, so stop shaming. Stop eating our own, because would you rather than have an MBA, Harvard MBA doing it, because they will screw it up. They haven’t touched patients. They need us, we need them too, but it’s a partnership, so let’s stop, and we were talking about Doc Vader and the healthcare administrator, so it’s funny because we did a podcast that hasn’t been released yet, I don’t think, but it’s coming out.
– It’s coming out next couple of weeks.
– You and I developed a new quality. I have to say it was Jessica Sweeney. JSP.
– JSP did it.
– It would be wrong for me to say that was me. It was a brilliant idea of how Doc Vader, actually I thought about it after, and it was so depressing, but Doc Vader resonates and I think a joke isn’t funny unless there’s a moment of truth in it. Otherwise it’s absurdity. Doc Vader is connecting to Zpac. Is that right?
– That’s right, and don’t let Pfizer sue me over that. It’s not a drug, but it is a drug.
– It can be a drug.
– That’s right.
– But people are connecting with that. If there were an index, I think Jess suggested we’d say hey the Doc Vader index dropped because people were more engaged, and people weren’t sure what they’re doing and that’s crazy. What’s he talking about? The problem is, people get it, and people are connecting to it and that’s depressing.
– I’ve always said I have a love hate relationship with my creation Doc Vader.
– Is that true?
– Absolutely, because in many ways I find him to be the repulsive voice of all that is wrong and he doesn’t have solutions His solutions are light saber the hell out of everything, but he’s got plenty of complaints, so if he sits there and he’s talking to the administrator and he’s like every day put the emperor light saber in my buttocks. Every day. Right in the cleft. Right in the gluteal cleft. Every day. That gets 11 million views. That tells me the DVI, the Doc Vader index, is very high. It means that people are resonating with a message that says that something is broken. Now that’s wonderful for raising awareness to actually change it. If we’re just complaining, it’s a sad expression of how broken we are. I have this love hate, so now I use it more as let’s do something absurd but let’s have this bigger conversation like you and I are having about how do we actually work to make it better and people you think are not on your side. Like someone from an EMR company are actually deeply on your side.
– Not only on your side, they are you.
– They’re you, they care. To be better. All the people in the company want it to be better. I think that that matters a great deal. I know people who have said, I will only work with physician led organizations. I mean people can get that. I think a lot of times it happens through partnership too. You’re seeing that more and more, because the truth is, we’re just not trained in some ways to deal with some of the business aspects so partnership where you have this dual or dyad concept, or you might have an administrator coupled with a physician leader can work, but the voice needs to be there, and I hope that it won’t get lost because we shame one another. I hadn’t really thought of it that way but I think it’s right. I’m probably bias in this but we ought not shame the people who want to be a part of leading what the future ought to look like. We don’t need to be managed. We’re smart people.
– That’s the central premise. That’s why managed care never worked, because who was managing us, wasn’t doctors,
– I think that is sometimes where there’s a total disconnect. I have a buddy who is an orthopedic surgeon, went to medical school with him.
– Does he have guns? Is he yolked?
– He was at one point in his life.
– Does he wear the cutoff scrubs?
– Oh my God.
– He would have. He definitely. You get right to who he is. I almost said his name but I won’t do that.
– That’s all it takes, but please continue.
– Great guy, and he’s working in a hospital and he is doing ortho trauma. Really difficult work, and all hours of the night and what not, and the sense I get every time I talk to him is that the administration keeps pushing down on top of him and they’re not really getting who he is. They’re willing to pay a little bit more money. He doesn’t want more money.
– He doesn’t want more money.
– He wants to be able to coach his kids baseball team. I think that piece of it matters a great deal, and we ought to make sure that our leaders have some understanding what it means to take care of the patient.
– Maybe to wrap that into this idea of capability, I think if we help our teams feel and be capable it means we give them enough resources, we give them good tools, and we give them latitude to take care of the patients and open up their pajama time, so they’re not charting at home, and do these ind of things like give them a sense of connection and you’ve said it. It’s the connection that a scribe allows, allows you to be present. In all your experience, I’m sure those best shifts were the ones where you connected.
– Where I felt like we made a difference, and I don’t feel like I make a difference when I’m documenting. You hear the top of the license thing and I don’t want to say it, but you know I just said it.
– I’ve said it and now I regret it.
– Give me another way to talk about it, but being a doctor or being a nurse, being a paramedic. That’s what you ought to be doing and that’s what you want to be doing. Anything that distracts from that, there’s gotta be a way around that, and you talk about team based care. I like it. Really good. There are all sorts of things. It’s not the document. Interestingly in our survey, it’s not the documenting so much that really gets in peoples way. It’s a problem, but it’s the stuff like the inbox and all the stuff that you feel like couldn’t someone else have dealt with this normal potassium. It’s all of that stuff that over time, thousand paper cuts, just adds up.
– The thousand paper cuts metaphor is very powerful. It’s visual and it’s also tactile. You’re like ow, ow, ow, ow, until finally you get sepsis and die, and I want to wrap up this conversation thinking a little bit about.
– I don’t want to wrap this. Let’s just keep going. How long has this been? What are we at?
– [Man] An hour and two.
– We’re about an hour in.
– We’re an hour in. What happened? Oh my gosh.
– I don’t know dude. Next time we gotta talk about UFOs.
– That’s crazy. There were so many other things I wanted to say.
– Bring them in. Because I just wanted to ask you about nurses because nurses are the canaries in the coal mine of our healthcare system, and they are dropping dead. Metaphorically speaking, and their documentation burden is really ridiculous. It’s crazy. We have to fix that in some way by changing the requirements, so yeah they’re happy to have electronic records and it’s easy to read the doctor’s handwriting. You’re unhappy because they have to document that they documented that they documented, and then we lost the connection. Maybe that was one of the things, I really liked about emergency medicine.
– It’s a team right there.
– It’s a great team and I had a great connection with the nurses. I fel the like they’re ones who kept me out of trouble and taught me. Always. Then we introduced the electronic health record.
– Now you don’t talk.
– Here I don’t have to disparage any vendor because we decided to build our server internally. Then all of sudden we weren’t talking to one another and by that time I was an attending already and the residents were doing what the were told which was to do their signoffs using the electronic health record, but then they wouldn’t follow up with a conversation with the nurse and there’s so much richness that comes from that connection and we lost that. There’s gotta be a way to get that back. I’m the optimist type of person. I believe there’s gotta be a way that technology will help us get it back.
– Electronic silos is the technical term for this phenomenon. We are all silod off. We don’t talk anymore. This is one of the biggest changes I noticed when we went live at Stanford is these nurses that were my friends that I used to know, that they would ave my butt on a routine basis and here’s the thing. It’s easy to, you can shower and pander to nurses all day and say how great they are, and that’s a thing to do, but what about the nurse who really needs to learn something about the management of CHF that will change how she cares for patients because she’s getting it wrong. The word doctor comes from the Latin docere, which means to teach, and we have lost the ability to teach nurses and to learn from nurses. To teach each other. Nurse comes from nutrire, which is to nurture.
– Is that right?
– They’re very good at that, but they’re also teachers just like we’re also nurturers.
– Put it together, and that’s the piece that, once you get away from that, first of all, it’s not as fulfilling, but it’s not as good for the patient either. I think about those moments in the chief medical officer role, you see a lot of different patient safety issues, and again complicated. You really have to figure out what happened, but breakdown of communication is a frequent thing and just taking a little bit of time to connect with something. Thinking about some of my, I missed an MI once early on. I still think about it. Early on in my career, and there were a series of reasons why that happened and all of them were around poor communication and that stayed with me. Luckily I did fine, but it was a real lesson for me, and I feel like anything that prevents us from communicating in a real way, in a substantive way, is bad for patients, and it’s bad for people who provide care.
– That’s the central premise of it and again, what does it get back to? The central core of why we are who we are and what we’re trying to do which is connection.
– We’re pack dogs, right?
– We are.
– That’s who we are.
– Apparently we evolved our frontal, all our neocortex purely to keep track of debts we owe each other in a tribe, names, faces, kids. This is the theory. One theory is that the reason we have this very advanced cortex because pack animals can remember even chimps and stuff, small numbers in the pack. We can remember about 100 to 150 tribal connections and keep score. Golden rule he once took care of my kid for me. I owe him one, and visa versa, and that’s part of the reason, and we use the metaphor elephant and rider. Elephant being our limbic emotional unconscious, makes all the decisions, but then this little guy on top the neocortex is our rider. He’s riding on the elephant. He’s the one who has to explain his elephant’s decision to the tribe. Very persuasive and good at expressing but we can make this guy stronger if we recognize how the mind works, and recognize we are tribal creatures who thrive on connection, and when you talk about loneliness you’re talking about a severing. It’s like losing oxygen. You become hypoxic. That’s how humans are.
– Isolation is another driver in burnout. One I think we had an idea might be the case but actually in the surveys, seems to be surfacing, and people feeling isolated is a real problem. Especially as you think your hospital, there was a time when folks used to come in to the hospital, see their patients, but not only see their patients, the primary care doctors. They bump into other doctors. They are specialists. They have a cup of coffee and all that. It’s been lost, and I think a lot about whether or not technology can fix that. Are you familiar with Fortnite?
– Am I familiar with FortNite? Come on.
– I got a 13 year old son.
– Tom’s playing it right now instead of watching this show.
– That’s what Tom’s doing right now. Tom. I’m from Jersey.
– I was born in Morristown.
– Where in Jersey?
– I’m from a town called Oakland in Bergen county. Not far.
– Bergen county. My mom worked at Bergen Pines psychiatric. Wow, okay.
– My whole family is still there, and I have a younger brother, and his kids and my kids get along really well, but they live in Jersey and we live in Massachusetts so they don’t get to see one another. They started playing Fortnite together. They have this really cool relationship now. In fact they game me all the time, which is fun because they’ll say I’m playing with T or Aiden. It’s okay. Screentime, visit cousins. But the truth is, they didn’t stop there. They started facetiming with one another. They’re using technology to be deeply connected to one another, and that’s pretty cool. I think it’s possible for it to happen, and I think that there must be a way the technology can create that community again in some way. We have a client right now, who are doing a virtual physician room.
– A lounge.
– Lounge. It wasn’t coming to me. They’re trying to figure out a way to connect people through this virtual lounge. Pretty interesting concept.
– This is fascinating, because it was interesting, what we found, I worked at two hospitals for most of my career and one was a place called Washington Hospital in Fremont California and that was a community hospital and then we would rotate back to Stanford. Washington Hospital, being a community hospital, everybody knew each other. There was a physician lounge that was big. It had a big TV and a coffee machine and snacks, and every single doc, would station themselves there with computer so they could chart, but we were still on paper, but you could look at labs on the computer. it was perfect. You could use the computer, for what doctors want which is to acquire data, and then paper was an easy way to input data because it’s incomplete. You don’t have to do that much, and it wasn’t ideal from a patient’s quality standpoint but it was great from usability standpoint and what ended up happening was all these connections. Hey you know bed five. Ms. Jane. What do you think? I know you wanted a catheter, but I’m really thinking she has GERD, because the more I talk to her and that sitting there, she can go well if you want me to catheter. I need your help. I need your intuition to tell me am I missing something. He’s like okay, I’ll go look at her like that in mind. He comes back and says it is good. You’re right. I wouldn’t have thought of it if you hadn’t told me this, and that just changed an outcome.
– That makes me think of the 80 million, 140 million ed visits, because when we’re so pressured for time and we’re clicking along, you don’t get that leisure time. It’s a luxury to have some leisure time to just think with a colleague around what’s happening with this patient.
– Absolutely. Can technology give us the leisure time back by taking some stuff off our plate, by making us more efficient in other ways? That’s the mission dollar question. I think so actually, I do. I’m not a luddite. People are like you’re always railing abut EMR. I’m like no, no, no, no, no. Because I want them to be better. Be angry, you should be angry. You should all be angry, I should say.
– Don’t worry, they are.
– They’re pissed.
– They’re gonna find you on the street Kevin Ban.
– Exactly, you don’t publish my address right?
– Tom scratch the address.
– Yeah, I think you should have high expectations, and there are all sorts of excuses like meaningful use, and we’re busy doing other things, but they’re just excuses. Ultimately as this transformation occurs and as we think more about a place where electronic health record can empower me, instead of getting in my way, we need to be creative and push it through.
– I’m excited for the future. I really am. I always have been. In the depths of my burnout, I might have lost sight of it, but I’m reinspired, because I get to meet people like yourself, like people who are working in companies from the inside trying to make everything better. Were there any other things you wanted to share with us Kevin while you’re here?
– What else can I tell you? We’ve been going at this over an hour.
– No we have to have you back, because.
– I’d love to come back. I really enjoyed this. I was a little nervous up front.
– Were you? Why? We’re just us.
– We didn’t know one another.
– True, we’ve never met.
– We’ve talked before, but we don’t know one another and now I feel like hey.
– We get to know each other in realtime on the show. People are watching connection form in real time because we only chatted briefly before the show. This to me is a really interesting thing, because if you guys wonder how do two colleagues, and we are colleagues. I’m a hospitalist, you’re an emergency doc. We admit to you. You admit to me. I come down and yell at you.
– You yell at me.
– But really we’re brothers from other mothers, right?
– It’s the concept of likemindedness. I cannot be connected to enough likeminded people. I always learn a lot, just like I have a lot in this conversation with you. It’s genuinely conversation and relationship I’d like to continue. This is the type of stuff that matters, and maybe it’s in some ways, demonstrative of what we’re talking about in general about what healthcare lacks, but yes, so I think I was a little freaked out up front but I feel pretty good about it now, and I’d love to come back.
– You’re a pro. I’m really impressed Kevin and I learned a lot and I’m glad someone like you is in leadership position and I’m glad you’re continuing to do great things, and I’m excited, and I’m also excited to have you back, so next time you come through Vegas let me know and we’ll talk about Italy. I want to talk about being a television news personality and there’s a whole list of things I want to ask you about. Dr. Kevin Ban chief medical officer of Athena health Emergency physician, former Harvard faculty, and all around amazing guy. Thank you for being on the show man.
– Thank you.