Problems with EMR, hospitals not co-managing patients, patients choosing between health, work and bankruptcy, medical tourism, doctor satisfaction and Jack Cochran MD of Kaiser goes in depth with his new book Healer Leader Partner.
Plastic surgeon (extra speciality in pediatrics) based in Denver for many years, Board of Directors for Kaiser Permanente for 8 years, became CEO –National Physician Leader of the Permanente Federation (20 years and lead 21,000 doctors and 10 million policy holders) and has even helped in the White House talking about health policy. Dr. Jack Cochran is also a sought after speaker for many organizations.
Skills to be a good leader: exceptional listener and a good balance not overly reactionary.
Number 3 cause of death in America is – Medical Errors.
Number 2 cause of bankruptcy is- Medical Cost.
Health care was 10% GDP and 2 journals in his specialty when he just started. Now 30 years later 18% GDP and 40 Journals and 100+ Blogs for knowledge. Warren Buffett said, “health care is the tapeworm of the American economy.” Dr. Cochrane goes into detail about what heath care cost inflation is and how it impacts society from lessons learned at Kaiser.
Remember the role of patient is involuntary and instantaneous. They don’t wake up and hope to break their arm.
How do you get doctors to broaden their sense of responsibility to their patients so they don’t become non caring and patients don’t have to figure it out on their own?
Family reality, they must ration health care at the kitchen table. What can be done when we have to choose between fixing the washing machine/ replacing the clutch in the truck and getting an MRI?
How do we keep health care affordable and have high clinical quality?
We also go through a little of the history of insurance and how sub-specialty of specialties has occurred.
Who can make a sustainable health care… GOV regulation, insurance, doctors?
Cost of MRI and Dr fees are too much … if we couldn’t get sued so easy would it make a difference?
We talk about how an MRI in China is $100 while in USA it can be $700, what is the deal with that? Also, Dr. Cochrane touches on medical tourism and surgeries in India vs UK. What surprised me is how often we run unnecessary tests to satisfy the patient not just to avoid litigation.
Should insurance companies reimburse their policy holders for many not spent and also cap the amount the CEO’s can make?
Can technology further the specialization of each doctor field. Crunch all the data of successful surgeries, life expectancy, pain relief… and then that lead us to making decisions more?
What has been the negative consequences of EMR to the doctor patient relationship and ways to make it easier for the doctors to implement without sacrificing the rapport?
Why can’t all the patients records be more easily accessible?
A disturbing analogy on how dysfunctional a hospital can be with their records and the 9/11 tragedy: the story is really worth the listen.
Doctors blame WHO and patients blame WHO for the mess we are in? Plus Dr. Cochrane gives another 3 questions about responsibility that he gleamed from his many years at Kaiser leadership.
What biases do you see doctors have toward patients?
What is causing patients to distrust doctors?
We end the interview discussing how hospitals could ban together, pool resources and even shut down repetitive departments to better serve the entire city. For example: 3 out of 4 hospitals have an oncology department but 2 of them see very few patients… could those two close down the oncology department and send them to the busy 3rd one?
Show notes can be found at http://www.adoctorsperspective.net/118 here you can also find links to things mentioned and the transcript.
Justin Trosclair 0:05
Episode 118 tizer legend discusses Keeler leader partner but we host Justin trust player today Dr. JACK perspective joint 2017 and 2018 podcast Awards Nominated host as we get behind the curtain look at all types of doctors and guests specialties. Let's hear a doctor's perspective.
Justin Trosclair 0:30
the time that you spend with me and your ears, working out driving cutting grass and whatever else that you do. We are a mere one week away from the six week podiatry series again we're going to have we got a guy that deals with the Olympics create his own shoe Medi spa, why should add that or maybe could you add that we got a podcaster probably seen it on social media. He interviewed me I interviewed him and then a practice management guy from podiatry. And then we'll follow that series up with a mastermind group student loans and a clinic Jim hybrid that's going to round out the next one to two and a half months. So stay tuned to those really excited about that. Did you tax done it's coming up quickly. Hey, you know I was interested in looking at you know, functional movement functional rehab at tell you what it is cool to see a kid grow up at six months, you know, it's done lift their booty up in the air, it looks like they're about to take off. They don't know how to like throw the arm out forward, but they're really good at flipping over when you try to hold them. You could really feel in them trying to turn so really cool to kind of study what she's doing and then be able to study that in humans and start looking at patterns that aren't functioning great for adults. In this I'm enjoying it. Yellow I'm talking about? I will tell you on the show. We've got the Dr. JACK Cochran will say it again and the introduction but my goodness 20 years he was the CEO, national opposition leader at the Kaiser Permanente Federation, pretty much manage 10 million policyholders and 21,000. Doctors, he lectures all over the place. And I was telling my friends about you know, Matt on the podcast today, he goes no, and that's telling me like the jack Cochran. I was like, Yeah, he's like, oh, man, that's a big deal, dude. Like I know. And anyway, so he's on the talk about his new book Keeler leader partner. So we're going to go over a few things like the health care costs, inflation has gone from 10% to 18% GDP, what's the, you know, bankruptcy? Number Three cause of death in America? What is that? You know, and one of the key points I thought was, remember, the role of the patient is involuntary and instantaneous, right? We're gonna we're gonna want to break their arm that day. So we just have to have to come see us. And whether that means they get the MRI, or they fixed the refrigerator mean, that's a real pocketbook question that they have to ask, will go a little bit of the history of insurance, and then how the subspecialties of specialties occurred throughout the world government regulation cost center here versus in other countries. And even though the standard of care and other countries could be just as good like some of the surgeons, should there be a limit to how much like insurance company seals make the role of EMR some of the negative effect and ways to mitigate that he actually has a, he didn't even like even the analogy, but he was reading the 911 tragedy report of like, what happened and how he was compared to a hospital. And you just gotta hear that story. It's near the end, it's really good. Plus, we he has about four questions about responsibility. Of course, all these questions that I asked, you just kind of gives a more than just an overview, actually here to answer some of these questions. So I probably could have went for like three hours with the guy, but I want you to read the book, you know. So I kind of like like, just give us a couple minute version that we all get, you know, get the gist of what's going on, and some real teasers and get us the one read the book. And I definitely think you're going to get a lot of good information from this episode as well, including how hospitals can band together to better serve an entire community. For instance, should every hospital have a stroke department or not? So we'll go through that and answer some of those questions, like I said, So without further stalling, all the show notes can be found at a doctor's perspective. NET last 1181 more little thing slowly, but surely, I'm getting transcripts now. So maybe not this week, you'll have it but in the future, check back and somebody shows will have the transcripts, I started with the top 10 of 2018 and 2017. And then I'll start filling in the gaps from there. All right, let's go hashtag behind the curtain.
Live from China and Colorado today in the show with a medical doctor. He's an author. But more than that, he's been a plastic surgeon in Denver. I want to say almost his entire career is on the board of directors for Kaiser for almost eight became the CEO, the permanent the Federation. And it's even council the White House and talking about like health policy and innovative policies and all those types of things. And so now, he's got his book out. It's called healer, leader partner, optimizing physician leadership to transform healthcare. Please welcome the show, Dr. JACK Cochrane.
Hello. Thanks for having me on.
Justin Trosclair 5:11
Absolutely. Man, Colorado. That's my stomping grounds. We had a clinic there for roughly six or seven years. And it's great to hear from Colorado people.
Yeah, good. Well, we just dug out of a big blizzard. So we're feeling the joy of springtime.
Justin Trosclair 5:28
Yeah, Isn't that crazy? Spring is always like the most snow timing. Yeah, this one you want to quit? You just like no, no strap on buddies?
Well, I think the way we love to create the beginning of an interview is is trying to find out a little bit about your backstory, you know, why did you become a plastic surgeon? And then you can fast forward a whole bunch of stuff? And then what was the catalyst to the write the book and then we'll have some specific questions you know about the book and topics in there and and sound Okay, sounds great. All right, take it away, give us a few minute introduction to yourself.
Yeah, I was I did not come from a physician family, I didn't have a long legacy of doctors in my family. So when I went to medical school, I guess I sort of assumed that would be what we would call a GP or a family doctor. And then when I got into medical school, you get exposed to all these incredible specialties and sub specialties. And I ended up with two areas that I really seem to like and one was pediatrics. Interestingly enough, I think the pediatric faculty at the school were so attentive to teaching that they really made the rotation and the experience very positive. But then somewhere I found in my DNA, I was a surgeon. And that was something that I didn't anticipate that realized that that was true. And so as I tried to find a field where I could do surgery, and also take care of kids, I looked at all the different specialties and the one that ended up being the best fit for me was reconstructive plastic surgery, the kids had definable problems and deformities, or burns. And if you were trained, you could really make a significant difference. So it really attracted me. And you know, they were, they didn't have to deal with, you know, death and dying, which was not something that I necessarily thought was gonna be my strength. So I became a plastic surgeon special interest in feeds, although I did everything. And after residency, I went into private practice, as we call it in Denver, and worked with a great couple of plastic surgeons learned a lot. But it was at a time when the insurance companies were moving into this thing called managed care. And it became harder and harder to get simple procedures, because I thought were really important for children, just to get them approved for coverage by an insurance company. So along the way, I began to work alongside this group called Kaiser Permanente in Denver, and they were relatively new, they've been there 15 or 20 years, and they had really good docs and so on, they recruited me to come over and start their plastic surgery service. And that's how I get get to be over there. When I was there, in a group practice with a bunch of good colleagues, my my colleagues decided I was, I had some potential to be a leader. So I was elected to the board of directors. And then once I was on there, I ended up being elected as the president of the medical group. So my leadership track was very, very quick. And as I say, in the book, why I think leadership is important training is that my medical background, I had four years of medical school, six years of surgery, residency, extensive validation, certification examination, you know, I really was well prepared to be a surgeon. And then when I went into the business of being a leader in the business of medicine, my training was just in time on the job, and trial and error. And none of those racing like what I was used to, but I got into leadership, it turns out that I had a knack for it. My colleagues said that the reason they thought I should be in leadership was I was a good listener. And I was very balanced and not overly reactionary. So whatever that man, I became president of the Colorado region, medical group, and we did so well that I then became recruited to be the national position lead for Kaiser Permanente. And when I left, we had 21,000 physicians and 10 million members and eight regions. And it was really a very stimulating, very challenging job. But that's how I got interested in the bigger picture of health care delivery, and not just taking care of patients one at a time. So that's how I got from being sort of pre med, to my medical training to leadership, and then leading Kaiser Permanente physicians,
Justin Trosclair 9:54
I like the way you answer that, because it's, it gives so much more depth into like, Okay, this is why I'm qualified to write this book, I wasn't just, you know, a doctor for 30 years at so much leadership and like you said, 10,021,000, doctors, you gotta be a special type of person, I think, to run those types of companies. So the questions I'll have we, you don't have to give the full answer, because that's what people need to read the book. But you know, I looked at the book, and I pulled some of the major, you know, headlines in the book and what you wanted to answer through them. So some of these are rewarded it combine the two together. So you know, what I'm saying is, when you answer them, you don't have to be like super long winded and give away the whole book, but just give us enough information where we're like, well, that's really interesting. I need to read more, because that's probably a 20 page. Right? Good.
Any other questions you like? Come on, man, that's three chapters.
Ok. So the theme of the book is the doctors are new to be leaders, they're typically kind of getting burned out, or the not making enough money, that they're making plenty of money dependent on your specialty and everything. But really, it all comes down to the it's about patients. It's about patient care. And there might be a trend going on right now that patients are the ones that are having to still sort through lots information, or they get like left high and dry. So is there any a simple answer a little bit of how a doctor can not really feel burned out so that patients don't have to be guessing what is the best course of action? Because you really didn't explain it? Well? Well, there's three, four options, and I don't know what's best for me,
right? That's really kind of the crux of the book in some ways. Because I do talk about the trajectory of the position career, how it has gone, and how it can possibly get better, and then really linking it to the plight of the patient. So I'll sort of give the capsule which is, in my career, three decades plus, in healthcare, there has been amazing advances, there have been better treatments, breakthrough breakthroughs, cures, I mean, just some amazing things have happened a lot of diseases. And yet, at the same time, there's two data points that still loom hanging over the care delivery results. The first one is the number three cause of death in the US is medical error. After oncology and heart disease, medical errors the third cause of death in our country. The second statistic is the number two cause a family financial failure and bankruptcy or medical bills. Number one is job loss. Number two is medical bills. So in the middle of this reality of fantastic care, and great results, we still have unevenness of care, unevenness of access, and medical errors. And that's a backdrop for why it's become harder for physicians to practice. When I started, healthcare was 10% of GDP. There was two journals in my specialty. Today, healthcare is 18% of GDP. And there are probably 40 journals and 100 blogs. And so many websites, there's so many places that knowledge is developed, published and shared that the old computer called the human brain has become just overstretched. And so the practice of medicine has gotten more complex and more difficult for positions. And that's part of our burnout. But I will just quickly digress to the family and what they're going through. And I'm going to talk about the physician career and how we can make it better. But before that, I must say that no matter how tough, the job is, for an individual position, or up or a specialty or whatever, no matter how tough Our job is, or how much it's changed. The role of patient is involuntary. Nobody, you know, some review hypochondriacs that we know, nobody wakes up in the morning and says, you know, gosh, it's been a while since I was a patient, I'd like to, I'd like to try that. today. I'd like to be a patient. Yeah, nobody wants to be the patient. Yeah. And so while I say it's involuntary, it's often also instantaneous. In other words, today, I'm fine. Tomorrow, some doctor told me I had cancer. Today, I'm fine. Tomorrow, I have a heart attack. Today, I'm fine. Tomorrow, I break my leg. So the role of patient is an involuntary and often instantaneous, and we must not forget that, because physicians, even though our jobs can be tough, we still have disproportionate impact on health care, patients still trust us the most for healthcare information. Now, as far as which health care professional, they trust the most overall, that's nurses were not number one. But for healthcare information, they trust us the most. And so patients who are facing difficult decisions around healthcare, and affording health care, remember, families used to pay nothing for health coverage, because their employer paid it. And then it was a couple of hundred, a few hundred a month for premiums. And then as it started to go in that 10% 18%
of GDP trajectory, health insurance costs went up and up and up. And patients and employers and governments kind of hit the wall, because this is wealth transfer from the family or the company or the government, into healthcare from other things, education and right kinds of opportunities. So families went to these high deductible, cost sharing kind of plans, and those were projected to be a way to save money, the premiums, instead of being 1200 a month would be 800 a month, or 600 a month. The fact is, it's also a bit of a gamble. Because if you get sick, you've got that deductible, that still doesn't go away. And so what happens with the average family, and we're not talking about just poor people are homeless, they were trying to average families every month with these patient
Justin Trosclair 16:15
They have discussions inside the family, I call it rationing healthcare at the kitchen table. And what families do is they say, well, Johnny needs an MRI because he hurt his knee playing soccer. But the clutch went out in my truck this week, my truck gets me to work, we've got to spend $1,000 this month on the truck, or Susie needs or tonsils out. But this month the refrigerator is broken, we got to spend the money on the refrigerator. So families at the sharp point of this affordability of healthcare are making decisions to ration their own health care every month. And so as for positions, while we have had legitimate decrease in our satisfaction in our career satisfaction, we have got to not only fix our own careers, but we've got to be sure we don't lose track of the patients. And so the premises of my book are. And so let me just explain how we got to where we are the complexity that I alluded to where we used to have one or two journals. And now we got all these journals and randomized control studies and many more medications and many more types of surgery, the complexity of knowledge, information technology, diagnostics, and therapeutics has overwhelmed us in terms of human brain. And so the first wave of complexity actually drove doctors into more sub specialization. cardiologists broke up into three different three different types of cardiologists before and so it wasn't just specialist but then sub specialists because of all the knowledge we have cardiologists who take care of the electrical system of the heart, others to take care of the arteries. So the first wave of complexity drove more and more medical sub specialization, and made it harder and harder for primary care to continue to keep up. And this was part of the source of dissatisfaction, my positions became harder and harder. And then one of the cure, alls we thought or was sold to us was this electronic health record, once, once we get the electronic health record, everything will get better. Well, not so fast. What we learned as doctors, and I learned as a physician and a leader of physicians was that when you drop a electronic record of the middle of a practice, it slows the doctors down, makes them less efficient. And it adds to the cost. And so the actual implementation is not the solution. Because
electronic records are not like new cars, they don't come with an owner's manual that says this is how you use this device to train farming, healthcare, much of the learning is on the job. And it has been very taxing for doctors, we have been very frustrated with electronic records and computers. And so it hasn't done all the things that should do. And it didn't necessarily make the complexity better. But along the way, we got more knowledge to the computer self, we became better at treating chronic conditions. And so the second wave of complexity, which further made it difficult to practice is patients who had these difficult diseases are now being cured. Or being turned into a chronic condition, HIV was no longer fatal, it became a chronic condition. And so patients lives to have second and third, complex conditions, or they live longer. I'm a baby boomer, we want to live forever. And so the second wave of complexity wasn't just that the knowledge and the information, we're deeper, but patients got multi system, multi organ problems. And the specialist alone was not enough. And it brings back in how do we create primary care partnerships with patients to work with and use the specialists to great advantage, but we have to have somebody who's coordinating and integrating the care. So primary care has come back. But this is all going on, on the base of a group of doctors who were trained to be single practitioners. In other words, the doctor patient relationship used to be where all the action was. And now we have teams and we have computers, and we have all these protocols. And it's really made it harder for us to to learn. And so we've had to learn how to work in teams, we've had to learn how to use the computers. And that was before the last 10 years when we start to get big data analytics and artificial intelligence. So the role of doctor has been increasingly difficult, increasingly complex and increasingly difficult for a lot of people. And the burnout rates are high. What we must not do is to say is take either extreme on this issue of physician burnout one extreme is get over it, you're well respected your well paid, lots of people like to be doctors just just get over it. That doesn't help any for people who are really, really suffering. The other extreme is Oh, you poor thing. It's just awful. It must be terrible to be a doctor. Well, that doesn't do any good either. What we have to decide with the position career is how do we study it? How do we actually take it as another one of our problems with our good science and our good analytics? And how do we study the career and we find out some things? Well, number one, it's better if if physicians do have some help with their computers, whether it's scribes, or other help, so they can spend more time with the patient, which is what we like, and less time with the computer, we also find that development of teams, so we're finding things that help with the physician career. And I think that's important. But just to include how I got to this book, is realizing that while doctors were frustrated, and in some ways, having a hard time, patients were still suffering. And so patients in Canada, the health care system, physically, socially, psychologically, financially. And if all we do is say, I'm here for your sore throat, I'm here for your broken toe. Once you're done with that you're on your own patients lose a partner with issues like affordability and access and and other things that that trouble them. So that's where I came up with this notion that the role of healer is our is our covenant with the patient. It's based on knowledge, trust, and skill. And so the role of healer is the sacred relationship that we've taken on because patients trust us with some of the most complex and frightening things that happened to them in their lives. So the roles dealers important. A physician as leader doesn't step away when patients say, but I can't afford health care, or I can't get access to this or that, or I don't know how to do this position as leader says, I need to I need to stay involved, I need to find ways to contribute beyond just my clinical skills. And that's a whole venture of our physicians take their credibility, their skills and their knowledge and contribute to improvements in healthcare besides just improving per patient. How do we make hospitals more efficient? How do we make communities healthier? Those kind of things. And the final role, healer, leader, and the final one is partner, which is we went to school based on our grades in the sciences we studied by ourselves, we were examined by ourselves. And we generally worked by ourselves for many years. And now the complexity of highly automated computerized world requires that we have partnerships we work differently with teams and nurses, and specialty in primary care and even how do we work with our it colleagues, so they don't just hand us a computer that frustrates us, and bugs us, but we actually help participated in improving things like that. So we have to continue to be healers and leverage that high ground to also learn how to be better at leading and better at partnering. And that's the whole premise of the book.
Justin Trosclair 24:29
Okay, some I break down a couple things that you were saying I was kind of taking some notes. I've noticed here, you know, I'm working in a hospital in China, they still have like the probably gonna butcher the name, but a Seaman's MRI machine. So it's really good machine. And it's only 100 bucks, hundred us dollars, to get a, an MRI, what in America, that same things gonna cost thousand bucks. So for instance, when my mom came visit, I was like, hey, look, let's MRI, all these different parts of your body. And when you go back home, if the needs it, you can just show it to you're not gonna have a report, they can always build the insurance for the report if they really need one, or they can actually, you know, just read it themselves. What's going on with that? Is there a way that we can? Or why hasn't the cost been contain more, when other countries are still charging so little? Is it kinda like the r&d part where now they say that with the medicines, the research and development, so certain countries need to pay their pay more because obviously a poor countries not to be able to afford it, but then they should still have access to it? What's your thoughts? So
the cost of healthcare is not a simple calculus, but one of the myths that we used to believe as well, it's all about utilization. And so if you look at the number of MRI per thousand residents in Canada, or something versus the US, it's very different. And so more work done. But that's not always true. Some Japan in some other countries, also a very high utilization of technological procedures and innovation. So it's not just volume. And it's not just the fact that we use and do more. But that's part of it, there's no question that we do a lot of procedures. If you need a third revision, joint replacement in the US, you're a lot, it's a lot easier to get it in the most countries, because most countries would just simply say, you know, we just don't believe that's part of our mission, we want to do all the joint replacements we can on people in their 50s through 80s, or 90s. But we can't just keep doing forever. So there's a certain societal expectation. The other thing is pricing. The United States has a higher pricing model for almost everything in healthcare. And you'll hear people who go to places for joint replacements, heart surgery, etc. And you don't want to use extreme examples, but to use one open heart surgery in India by Dr. Debbie Shetty, who's a world known heart surgeon, pediatric neurosurgeon whose results stand up with the best in the United Kingdom, because you know, India's come, a British Commonwealth country, is results stand up the best in the UK. And he gets the surgeries done for like 1200 dollars for the hospital, surgeon, nurse, etc. Now, that doesn't relate to the United States. But the fact is, when somebody like that can get the results that that are just as good as ours, you start to think why that's why people do medical tourism, they go other places and get things done. Right. But it does show that the pricing is part of the equation, and that's been shown and how people look at how much do people charge for a total joint replacement in Canada versus the US, China versus the US, etc. And it's very different. So pricing is part of it. utilization is part of it. And the other thing is expectations of patients, we have a sort of an undercurrent that is not it's not always in not necessarily true, which is more is better. And it comes out of this. I go to the doctor, I twisted my knee, they say yeah, you put uni I'll examine you, I think you need to get a brace, use some crutches and see me if it's not that are in three weeks, some people think, wait a second, that's not enough, I need an MRI. And I saw this play out when I was in a in a summer educational program with a group of international students. I was in my 50s at the time, and they would play soccer and twist their knee or this or that. And the university would always try to ship them off to the emergency room for an MRI and people from Australia and Holland and Italy thought it was sir. They said Why would I have an MRI? Well, you have to we you know, we have to be sure. So there's this patient expectation that I'm not getting good care, or the doctors not attendee where the doctors not concerned or the doctors not competent, if I'm not getting all these interventions, and that's that undercurrent of expectation doesn't correlate with really the the good science of when things are truly indicated. And we should never withhold care when it's necessary. And you know, keep people from getting what they need. But there is some real discipline and science around what works and what doesn't. One of the great examples, as we see these new generation medications that come out for everything from rheumatoid arthritis, to surprise us to cancer, if you take a look at those medications, they're all of a sudden, no longer 50 or $60 a month, or 1000 or $10,000 a month. But when you track new medications over time, the number of them that have modifications of the indications is very, it's a majority, the number of them that find new problems, and complications is a very large majority. And then the number of them that are taken off the market or two. It's not a majority, but there's also a significant number. So we have a tendency to jump on new new medications. And then later we find out that there are some problems with it, or there's some other issues. And that's just part of our system, we we have this this notion that we want to get the best and we want to get it now. And that grew out of a system that was employer based insurance, with no co-payments know coinsurance, and no sharing and premium. So we grew up thinking,
Justin Trosclair 30:32
cost me a penny, what about this in our country, the doctors can get sued, I don't know there's certain states, they make it harder to sue a doctor. And I don't know if that's translated into doing less services, because it seems like a lot of medicine can be said, We don't need to do the MRI, really, we don't even have to do the X ray on that sprained ankle. But if I don't do it, and there's something more going on, then I get sued. And it's this whole big thing. But you know, for a lot of Ms. k stuff, we don't need x rays. We don't need the MRI. You can go to PT or Cairo or you know, somebody who can who knows how to diagnose it and treat it, you know, send them off the people that actually do that, you know, all day. So I guess the question is, if litigation was harder to do, would there be less, Tara ordered?
Well, there are people who would say to you, actually, just on the science doesn't support that there's just no real good science that supports that. But I think that, in general, there's no question that physicians practicing medicine in the United States have in the back of their mind, that possibility, and what what people that have not had the responsibility of the clinician or the physician, but they don't understand is just how troubling it is to get sued. And it was there, you know, people get sued, it turned over the lawyer doesn't cost you any money nights. It hits you at your at your core. And it's you at your your soul, and your sense of values that we know there are certain people in any profession that are not as dedicated or as ethical, but the overwhelming majority care deeply about their patients and their results. And so lawsuits are very debilitating and very difficult and very hard on most of us. So yes, there is that little flicker in the back of our minds that we certainly don't want to get sued. Even though there are studies that show that they don't think it necessarily increases that much. I think the fact is, if you look at the cost of liability insurance, if you look at the number of lawyers in the US to do medical litigation versus other parts of the world, it is a very significant problem. However, it would be short sighted to say once we fix that everything gets all hunky dory. There's the other thing of patient expectation is the other thing a price. There's a The other thing of just the attractiveness of new and fancy therapy. So lot of those things go together. And part of its just the the expectation of the American, the American we we kind of think in healthcare, we'd sort of like to have the miracles now that that set of expectations, I must say has been changed over the last many years as more cost sharing came to bear on patients and families. And cost sharing was was sold as a way to eliminate or minimize unnecessary or, or extreme demand. And that's a little bit of a simplification and a little bit one sided, because it essentially assumes that there's a whole bunch of unnecessary care. And if we just put a price tag on people won't ask for unnecessary things. Well, the inconvenient reality that we've learned is two things. Number one, if you increase the costs the individual out of pocket costs, costs, sharing deductibles, whatever it call, where they have to pay out of pocket, as I alluded to earlier, they ration healthcare inside the family at the kitchen table. But if you do had seen him in cost sharing, two things have been discovered overtime. Number one, yes, it does diminish the demand for unnecessary or marginally necessary care that on the one hand has some positives. The inconvenient unfortunate other side of that is, it also decreases the demand, or the request for necessary care. Patients simply say, I just can't afford it. And so they don't get their prescriptions filled. Or they take half of it, or they don't get it refilled. It is it is true that cost sharing decreases some of the unnecessary demand, but it also decreases compliance and necessary demand. So it's not a cure all and and has to be sought, fully deployed, because we don't want people to need medication should not get them because the cost.
Justin Trosclair 35:08
Yeah, and I'd venture to say here at the hospital, there's some patients that I work on that I would normally might not have worked on in America, because they have no other options here. And I just take it easy on what I do, you know, just there's just scale back what I can do, because it's like, it's this or nothing. And so if I can get them some relief, then I didn't you know, I did my job. But in America, I'm kinda like, well, I don't know, in go wrong and go sideways. It hasn't yet. So it kind of is building my confidence to have maybe I was being a little too conservative sometimes. But um, when you referring to the electronic health records, maybe having to like hire, and it was a private practice, not as many private practice doctors, the most of them are getting bought out by big corporations and stuff. You
jumped over to have a scribe?
Justin Trosclair 35:51
Yeah, well, in America now, sorry, to hire a scribe. I don't know if a lot of doctors or hospitals would want to pay to have some someone doing that all day or just a nurse that's already working there would do it. Yeah. But it seems like I've heard pieces like you know, the doctor just stares at a computer the whole time just clicking buttons. And I don't really feel like I'm getting the care that they used to get. But I know that they have to use this. So what do we do with that?
Well, first of all, as I said, on day one, when you put in an electronic health record, to negative things happen, you slow down your doctors, and you increase your cost. And neither one of those is going to make healthcare better. In and of itself. What I've seen, it's not quite a bifurcation. But I've seen physicians who just suffered with the computer, really hard time using it hard time figuring it out. And even not worse. But even in addition to that made it very difficult for them to relate to the patient, because they were spending so much time facing the screen. Well, there are ways to configure the room in the screen, and all that sort of patients and doctors going to get the screen together. And there are positions who invest significant time to get really good at the computer. And so the best world is to have a computer that's user friendly enough and has the right kind of
artificial intelligence so that they don't have to just type out everything that they can use, you know, clicking certain messages and certain diagnoses, etc. So design of the computer computer system makes it makes it better and easier. And some of that as they happen. And others are just the doc say I've got to invest a lot of time right now to get good at this. So that I'm not always rebooting and re learning things. And so there are super users, they're actually walk out at five o'clock 530 from their office happy and have used the computer successfully all day. And there are others who are working their inbox and all that at eight or nine o'clock at night. So it is far from a simple solution or simple answer. But because of the safety of having that electronic records accessible, nobody's going to go back to paper and, and the the complex patient right, you have to have some way to find their their care. So in the second the second wave of complexity, multiple patients with multiple system disease. The first one is just the medical knowledge, information and technology. But these patients that require coordination and and team care, if you have a complex patient with heart failure, and they're seeing a cardiologist, with a paper or computer chart in the cardiologist saw was that is not connected to the pulmonary Doku seeing them for some pulmonary hypertension and cough and difficulty breathing. And who was also seeing a endocrinologist for diabetes. If those doctors are not connected with a similar or a compatible, or can be interconnected record, you have three very complex problems being solved in silos. And I'll tell you the I hate this example. But the the task force that examine the 911 tragedy in New York City, the 911 Commission, when they came to their conclusions, they said, what was amazing, shocking and disturbing was that the FAA had a lot of knowledge, including knowledge about the planes in the in the hijackers, the FBI, at certain information about some of this, the Secret Service had some information, the army had some information, the police had information, all of these entities had information, but they were not shared, connected or linked. And it had they been, then the FAA might have picked up that there were people doing pilot lessons at a certain place, that the FBI had an interest in because of their background, and that the police seen something on it. So when the 911 Commission tried to explain what went wrong, and this is right out of their report, and this is this was just stunning to me. They said there was so many people that had lots of information and even had the right information. But they were functioning like a bunch of specialists in a hospital. All these high powered people had great information, but they weren't talking to each other, or communicating other than through the chart. And I thought the 911 Commission trying to explain the worst tragedy in the history of the American culture, goes to the my profession, and says it's just like a hospital. Now, I still find that just shocking, that they actually think that's how hospitals work. Now, unfortunately, the number three cause of death in this country is medical error. And by the way, I think people say that's, that's not true anymore. It's true. It's still true. It's it's 400 and some thousand deaths a year, or due to medical care documented, it's a jumbo jet confirmed in 2018. Still true number three cause of death. I had up accidents, and ahead of certain other illnesses, but it's behind only heart disease and cancer.
Justin Trosclair 41:22
Well, real quick, because, you know, I'm not sure how it works in in a in a major, major hospital. I mean, I know in private practice, it's Oh, you gotta sign this hip before my you can assign that HIPAA form, oh, we didn't get it in time. So it's a real pain. But in a big hospital, are you able to see the entire patient record? Even if you're working on the spine? And this person's working on the heart? And this guy's on the lung? Can you all see those notes
that would represent the ideal state? It does not exist?
Justin Trosclair 41:49
I don't understand why it's not in it. And what I think they sold us, yes, everybody has to do a shark is going to be so great. Oh, great, then you should have my record from from Dr. Bob down the street, you're like, No, no, that's not how it works. We have 1000 different literally like programs that we can use, they don't talk to each other, nothing saved in the cloud. For everybody else, the notion
behind the legislation around interoperability, the interoperability says we're not going to drive all the computer companies out of business for one, but we want to have these rules and regulations, which says, if you're going to build a new computer system, it has to be interoperable with the old one, so that you don't have that continuing silos, we are a long way from that. But that is that's how you would design it. If you were starting today, you would say we're going to design a computerized system that's going to be very standardized that doctors like customize it like I want my little thing, well, we're going to have to accept certain things that are standardized. And then we're going to have to learn how to work with them, just like we do. All computers that were handed, you know, talk about is this notion of affordability, which doctors often maybe not so much now. But traditionally, physicians have felt like my job is to take care of the patient. My job is to be available and knowledgeable and compassionate and provide a great care. And affordability is about the lawyers, the insurance companies, the hospitals, all these other entities and I'm I'm solving the affordability issue by pointing fingers at other people well, 83 cents of every healthcare dollar is spent on health care. And those decisions are still made overwhelmingly as outgrowth of a relation between doctors and patients. And the doctor has a significant say and so all this stuff about, you know, medical malpractice, and are you up to date? And do i do i get the best and brightest of everything that's always been in the background. But now that patients are sharing costs, they often go, I don't want him or I do you have a cheaper chest, can I get an X ray or a CT or some and one of the quotes that I thought was, again, very disturbing, because of where it came from was Warren Buffett, as he's become more interested in the healthcare, he even said that corporate america didn't need the tax cuts that the Trump put in place where we need is to control healthcare, inflation. And he said that healthcare is the tapeworm of the American economy. It just continually drains all of the blood and all of the nutrients out of the American economy. And I've often said that healthcare inflation is like untreated diabetes or blood pressure doesn't necessarily you don't necessarily know or don't receive it, or don't even have any suffering from it until you have a stroke or a heart attack or something like that. And and Buffett is right, because when you go from 10% to 18% of GDP, which is my career track 8% of the GDP, that's the whole gross domestic product of the whole country has been diverted, yeah, from education, and job and raises and infrastructure and potholes and rehabilitation, from all those things into healthcare. Even the state of Massachusetts, who's been for over 10 years has been working on health care reform, even they still almost all the increase spending in the state goes to health care. And so buffets, right? It is, it is an emergency that nobody is fully endorsed. And yet
hospitals, pharmaceutical companies, lawyers, doctors, many of them are still making good money. And the question is who's responsible? Who's going to own it, and it was gonna make it happen? Because it's a, it's still getting worse?
Justin Trosclair 45:41
Well, this isn't going to fix all the problems with my two cents. I'm wondering if all these health insurance companies has some sort of Co Op where Hey, all right, you're the CEO of this gigantic Corporation, I understand you can make a million or a couple million, but a lot of them are making 18 $20 million, something, you know, saw a lot of a lot of profit. So I'm always wondering, is there not a way to set up the insurance companies kinda like a co op where, hey, we collected 250 million dollars this year, but we only spend 100 million, well, instead of it just going to our profit or shareholders, that money now gets distributed back to everybody who paid premium is this year. And it seems like now that money's coming right back to you. And you can spend on how you want Yeah, well, but that's not how it works. It just concentrates All eyes are blue cross.
But the four questions that position should should ponder. One is what kind of ancestor Are you going to be? And that's a combination of, am I going to leave behind my grandson to enter? Am I going to leave an economy that my grandson can survive in that sort of thing? Number two, is is excellent. Good enough, which says, Yes, we can cure cancer as we never used to cure but of patients can you can even afford the basic treatments? is excellent. Good enough. And it refers to are we are we doing our jobs, if all we care about is clinical quality? We've got to also care about fairness, access, etc. and affordability. Third question is, how big is our responsibility, and that's where healer leader partner comes in, which is, we can't just sit on the sidelines and say, I did my job because I did a good gallbladder operation. And the patient got a $70,000 bill, because I was out of network or something in the patient now is that mortgage their house to pay for it? And but the fourth question is the one you're asking now, which is, in many ways, the most wicked of the four questions, which is how broad is our accountability. And I would use an example of a city. And this is what you're alluding to. So supposing there's three hospitals or three organized systems of healthcare, including doctors in a city of a million. And supposing you've got the biggest system and your system takes care of 400,000 of the million. You are a citizen, a neighbor, a physician, a friend, a participant in the city, and you're responsible for 400,000 people for their care, you care about the other 600,000? And the simple answer is well shows I do really do anything unusual or out of the ordinary to demonstrate that and so those would look like two competing hospital sit down and say, you know, we both have stroke units, we both get about seven admissions a week, we should but not both have stroke unit one of us should close. We both have oncology, we both have cardiac surgery programs. They're both low volume, who's going to close? Those are the kinds of questions or we have a new way of treating strokes at our hospital, we're not going to share it with you. It's a competitive advantage on the profit. That's the wicked for Yeah, which is how big is our sense of responsibility. And that's where you say, I'm a full citizen of a city of 1 million, but I will only commit to tinker afford 1000 people. And by making that commitment, I will actually turn my back on 600,000. That's a wicked question. And then I see hospital systems that refuse to acknowledge each other or find any way to work together, whether it's on the nursing shortage, on on ambulance care on uninsured care, they all continue to compete. And, and they miss the Warren Buffett message, which is you're all competing to the tapeworm, you're all competing. But the other thing we do in the United States, as you as you say, will pay a CEO 40 or $50 million for a good year. doesn't take too many of those. And and there's not too many people making that much money. So it's very hard on the way up the corporate ladder to say, Okay, now it's time to stop your salaries 200,000 or 4000, which still pretty good money. But it's time to stop and become you know, very socially conscious person. I think we all we all the incident the incentives the top or are really very seductive to be very successful. Sony, we had a community level, some communities have organized around, we want to do what's best for the community, we are going to force the stakeholders to come to the table and talk to each other. And that's usually a mayor or governor, some person of substance says I'm going to convene you guys, you're going to come together. And we're going to talk about the distribution of care in this community and affordability, and why you have all this duplication of service and why we can't find some other way to do it. London, 15 years ago had 70 hospitals took care of strokes, they now have 12. And their results in the treatment of strokes of gun remarkably better because they got 12 Super centers, things 58 hospitals don't have any revenue from stroke care. 58 hospitals gave up a line of business. And so for that to happen, there has to be a real conversation around that. Because it's very hard to say to a hospital CEO, we want you to take 15% of your gross revenue away. And we don't necessarily have anything to give you that. So that's the part that surprises me. But that's where communities start to think together. Yes, I 4000 people and directly responsible for but I'm a citizen of a community of a million. That's the fourth question. That's the wiki. And that's where Warren Buffett ought to be asking those questions. And I think it's,
Justin Trosclair 51:12
I think it's Yeah, I would think that some of these 15 hospitals, they might already be set up with something else. So like, Okay, you've all had ortho surgery. Now we have 15 hospitals that are gonna do ortho, and you just sort of mix it up and mix it around and strategically placed them around the city around the country so that everybody has a better way to access that they don't all have to be in London as a whole, the whole north side of the country is not going to have one. Even down here. My high school zone has an MRI the public hospital doesn't have when they only have CT. So we get a lot of patients just coming for the Where are you located? I'm in the union of China.
Okay. That's so there. Yeah.
Justin Trosclair 51:47
Yes, Southern your Vietnam.
So you know that they're not trying to purchase one. So they just didn't all the clients that need a, an MRI to us, and then they go right back to wherever they were. And we don't poach them, which is kind nice. Like a Cochran, is there a website where people can get more information? Or do they just need to go to Amazon and pick up your book,
Amazon thing at my book, I have a website, www dot check Cochran md.com, that has some of my papers. And I'm also a professional speaker, people want to have me speak. But yeah, I, you know, this is very self serving. But this is this a niche book, it's not gonna be some big commercial success. But I really hope people read this book, because the lessons that I have learned and that I have shared are so attainable, and I wouldn't say they're simple, but they're pretty simple, straightforward. And it really talks about leading your fellow man, because doctors are very independent people. And we have to have some sense of how physician leadership can be effective. And this book is like a manual. And I say that people who really become good leaders will have two copies of this book, one in their backpack and one on their day, because they will be referring to it so often, is definitely a conversation starter among our own peers, for sure. Yeah.
Justin Trosclair 53:07
All right. Well, Doc, thank you so much for coming on the show. I know, like I just said, If I can get more people to listen to this is very good chance that there'll be a lot of Facebook conversations about Hey, did you read that book? What do you think about this and part of it, sometimes it's just getting the conversation going, so that you can make bigger changes in the future. So again, for taking your time and coming on the podcast.
Thanks. Thanks for your time and for the opportunity.
Well, that wraps up another
Justin Trosclair 53:35
episode, if you can send me review that's dot net slash subscribe, Apple, Google Stitcher, Android devices, you just click that button, it'll take you exactly the page, you need to you can write a review, hopefully a five star review, I said it does help for other people to discover what we're doing here. And one thing I haven't really talked about too much is the doctor's perspective. NET slash support page through about a host a cup of coffee, go for it, is you want to pledge a little higher fee, there's buttons for that there's even monthly recurring for those who feel like wow, this is like the cheapest mentor coach program I've ever seen. Because you interview so many different kinds of doctors and and have been able to implement things that I've heard and it works. So monthly recurring payments, which also you can get you my books for free t shirts for free. The first book, you know, that deals with health and exercise, getting on a diet, getting your financial health in order as well, things to learn in China, you know, that books is available as well. And one thing that I don't have, I don't have like a full blown page about coaching and things. But there's a little button there. I've had people request, hey, doctors and non doctors asking me can I do more than just answer a couple of questions? Or could you be my coach for a little while and I say yeah, we can do that. So something I haven't really advertised but it's something that I can do and do whether it's marketing, some strategies for new patients growth, those types of topics, you're interested just email me Justin at a doctor's perspective. NET if you have any ideas for guests, please send an email Justin at a doctor's perspective. NET I'd love to hear who you think would be good on profession that you may not have heard yet. And we've got over 100 episodes is gonna be like our third year super excited we're going a little mini series like we've been doing which has been fun. I hope you've enjoyed them as well that's that's the feedback I've gotten want to remind everybody that we have some great affiliate links available if you're into instrument assisted soft tissue manipulation, we've got the edge tool and we got the hot grips stage about 10% also with the edge you've got the like blood pressure cuff restriction system you got the G sweet inexpensive Mr in case you're talking to him cash practice and of course I got my own electric acupuncture pin to go with the needle acupuncture book time, you know have a bundle set bringing them all together for a great price muscle have the free downloads at a doctor's perspective, net slash blueprints. And more lately I've been doing is substituting a fifth one like I've done a neat and depend on the guest I might do a different type. So check back there. You've got the primal paleo grass fed protein bone broth style, save 10% on that no sugar, allergy free, gluten free, dairy free all those types of things mentor box get taught by the author, we got set preset for those floss bands. And you may have heard about on one of the episodes really like those. If you want to know what hosting us for podcasting, blueberry, pure VPN, that's one of those ones I use to help keep my payments secure as well as access the internet more safely in the Amazon products that you might want. Click the link in the show notes pages. So all those resources can be found a doctor's perspective, net slash resources. There's also t shirts at.net slash t shirts, put up some new designs from time to time like making lemons out of lemonade shrimp Oh boy, plus all the Chiropractic and podcast swag that you could want. As always, listen, critically think and implement. Have a great week.
We just went hashtag behind the curtain. I hope you will listen and integrate with some of these guests have said by all means please share across your social media. write a review. And if you go to the show notes page, you can find all the references for today's guests. You been listening to Dr. Justin trust Claire giving you a doctor's perspective.
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