Reunion Kick-Off with Khullar, MD '14 and Forman, MD

August 04, 2023

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Alumnus and academic physician-journalist Dhruv Khullar MD ’14 and Yale health policy expert Howie Forman, MD, wide-ranging conversation about critical challenges and opportunities in medicine today.

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00:00Good afternoon.
00:05Welcome everybody.
00:06I'm sure we will have stragglers.
00:07I'm Nancy Brown, Dean of the School
00:10of Medicine since February 1, 2020,
00:12which means that I'm in my 4th year,
00:15but it's all been fairly compressed
00:17by this little thing called COVID.
00:19So this is our second in person
00:23reunion and the weather has
00:26cooperated and great turnout.
00:28We're expecting a big number and
00:30so really glad that you're here.
00:33I'll share that tomorrow morning at
00:35I think 9:30 I'll be presenting a
00:37state of the school so that you can
00:40hear a little bit about what we're
00:42up to and you'll I hope for take of
00:45all the other events and tours as
00:48well to see what's going on here.
00:51I'd also encourage you to explore New Haven.
00:53It's changed a lot becoming sort of
00:56the IT city and attracting young people
01:00who aren't even affiliated with Yale.
01:02So it's it's really terrific.
01:05I want to thank you for your support,
01:08particularly those of you who are volunteers.
01:11It makes a huge difference.
01:13It makes a difference to our
01:15current students,
01:15and we'll talk more about that as well.
01:18And I'll be sharing with you some
01:21introductions tomorrow of some
01:23new of a new alumni liaison whom
01:26you'll have an opportunity to meet.
01:28You have been very generous over the
01:32years and I'll tell you that since July 2018,
01:36the gifts from our alumni total
01:39about 4.6 million,
01:42much of that focused on financial
01:44aid for our students and we are well
01:47on our way to making Yale School of
01:49Medicine debt free a priority for us.
01:52And so thank you for that as well.
01:59So now I'd like to introduce our
02:02guests and starting with Drew Coolar,
02:05who is a class of MD,
02:08class of 14 and left us to go up north
02:13to MGH and Harvard Medical School,
02:16but where he also received a
02:19degree from the Kennedy School,
02:22a Masters in Public Policy.
02:23And Drew has been very engaged in
02:28the Center for Public Leadership
02:30in thinking about policy around
02:36professionalism. In particular,
02:38he's recognized by LinkedIn as among
02:42the top ten healthcare professionals
02:44under 35 or was recognized as that.
02:47I I I think we should just say it.
02:50You know that that's true because
02:52by the National Minority Quality
02:54Forum as 40 under 40 in leadership.
02:57So we'll keep going up as the age
03:00goes up and a number of other awards.
03:04I I think you had a chance to see some
03:07of his articles from The New Yorker and
03:10other and and medical journals as well.
03:12Gemma, New England Journal.
03:15Thinking about topics from
03:17professionalism and burnout,
03:19and particularly thinking about the impacts
03:22of COVID-19 beyond the pandemic itself.
03:24But in terms of how we
03:28how we respond to those stresses
03:31and what implications it has
03:34for everything from economics to
03:37how we train medical students,
03:41conversing with Doctor
03:42Cooler will be our own.
03:44Doctor Howard Foreman and Howary
03:46is something of a fixture here,
03:49not just here in the School of Medicine,
03:50but across the university.
03:53Sharing truly in one single person.
03:56Embodying our collaboration
03:58directs the MDMPH of MD, MB.
04:01A program also has a rule in
04:03the School of Public Health,
04:05obviously a a role in the
04:07Department of Radiology.
04:08He cohosts a podcast
04:10called Health and Veritas,
04:12and I've had the privilege of
04:15participating in that podcast and I
04:17will tell you he's probably the most
04:20prepared interviewer I've ever had.
04:23He's worked in the US Senate as a
04:25health Policy fellow on Medicare
04:28legislation and a constant proponent
04:31of evidence based responses to COVID.
04:34So I'm gonna stop talking and
04:36let these two bright minds
04:40stimulate your thought as well.
04:41So thank you
04:42very much. Thanks very much and
04:48really, sincerely thank
04:49you all for being here.
04:51And feel are we on? Yep. Okay.
04:53And let me just say that we're
04:55going to have time for questions.
04:57So if anybody has questions,
04:58just sort of at some point put your hand
05:00up and I'll make sure I get to you as well,
05:02because we want this to be
05:04as interactive as possible.
05:06First, I just want to thank
05:07Drew for doing this.
05:09I've known him for I think about 15
05:11years now or something in that range
05:12because I first met him right in
05:14between college and and medical school.
05:16He went to Yale College as well.
05:19And I just want to say that his career,
05:21you can't even capture it in a
05:24simple introduction because he
05:25has been very thoughtful about
05:27how to prepare himself to have a
05:30career in both communicating the
05:33way we think about medicine,
05:35the way we think about healthcare,
05:36how we can improve healthcare,
05:37but also doing the scholarship that informs
05:41our decision making around healthcare.
05:43And he's also a practicing clinician
05:45as well and he is well worthy of being
05:48the the best selling writer that he is.
05:50And we're really fortunate to have him here.
05:53I want to just start off by talking about
05:56this role that you've taken because you know,
05:59you're nine years out of here,
06:0110 years out of your original
06:03graduating class.
06:04You went to the Kennedy School to
06:06get this public policy degree.
06:07You started writing at a very early age.
06:10You're a grant funded researcher
06:12in an academic department and
06:14you practice clinical medicine,
06:16but your writing really touches the
06:18soul of individuals by pointing
06:20out the challenges,
06:21whether it's about COVID misinformation
06:24or whether it's about something like
06:27the end of the pandemic and and why
06:30that is and is not good for people.
06:33How did you know so early on that
06:35this is what you wanted to do?
06:36Like tell us a little about what
06:38what informed your decision making
06:40at each step of the way.
06:42Yeah I I just,
06:43I just want to start by saying how,
06:45how special it is to come back to Yale.
06:47And I'm sure all of you feel the
06:49same way and you know been in a
06:51number of different places at this
06:52point and different institutions.
06:53But every time I come back it just
06:56reminds me that this is a place
06:58that it is really special and has
07:00helped me in my journey and and
07:02helped countless other people.
07:04And I would be remiss if I didn't
07:05say that how we is one of the
07:07people that really has helped me
07:08do the types of things that I want
07:10to do in my career and give me the
07:12encouragement to do so and so.
07:13So I I want to start by by
07:16acknowledging that you know,
07:18I I it's hard to say exactly
07:23when I think about the path.
07:24It wasn't actually something that
07:26I have been thinking about and had
07:28it all sketched out ahead of time.
07:30I think you know Steve Jobs who
07:31said it's much easier to connect
07:33the dots looking backwards than
07:34forwards and that certainly has
07:36already been the case for me.
07:39I think I always had a sense
07:41that I love clinical medicine,
07:43but I also wanted to think about
07:45the system around medicine and
07:47why we are either able to provide
07:50excellent quality care or less
07:51than excellent quality care.
07:53And what are the determinants
07:54of those things.
07:55And once you start,
07:56you know, looking into that,
07:57there's an endless number of
07:58things that outside of the hospital
08:01room contribute to our ability
08:04to care for people in the way
08:05that we want to care for people.
08:06And so for me,
08:07that was kind of the the motivating
08:09force and and took me to the Kennedy
08:12School to to try to understand
08:13some of the policy levers there.
08:15I took a number of writing classes.
08:17I looked up to people like Oliver
08:19Sacks and Atul Gawande and
08:20and to Darth the Mukherjee.
08:22These people who I thought so
08:23beautifully were able to capture
08:25what it meant to be a doctor,
08:27but also communicate both the
08:29challenges and the joys of the
08:33profession to a very broad audience.
08:34And so that has been something
08:36that that I've tried to start
08:38doing in my own career,
08:40I will say just as an aside.
08:41So I've had conversations with Vivek
08:44Murthy when he first came to Yale,
08:47with Mandy Cohen when she first came to Yale,
08:49and with you and a lot of other
08:51people as well, but three people
08:53that you may be familiar with.
08:54Mandy Cohen was just nominated
08:55to be head of the CDC yesterday.
08:58And I do want you to know you're
08:59in the category of Mandy Cohen
09:00knowing what you wanted to do,
09:02like my memory of what you wanted
09:03to do aligns very well with this.
09:05Vivek Murthy, on the other hand, not at all.
09:09He has turned out to be an
09:10amazingly compassionate physician,
09:11but he never mentioned Surgeon General,
09:13never mentioned public service
09:14even at that time.
09:15So I do want to credit you
09:17with actually knowing that you
09:19wanted to go in this direction.
09:20We had that conversation
09:22about a public health degree,
09:23a public policy degree or a
09:25business administration degree
09:26very early on in your time here.
09:28And you chose wisely,
09:29as they say.
09:30And you started writing with some really
09:32senior smart people in the field.
09:34And that informs some of the
09:37stuff that you've worked on.
09:39All of you have come through
09:41the sort of medical industrial
09:43complex one way or another.
09:45And one of the things that
09:47I've observed and perhaps been
09:48embarrassed of a little bit over
09:50the last 15 years or 16 years is
09:53that when I teach my undergrads,
09:55you know,
09:56starting when Obamacare was passing,
09:57I started saying we're going to be moving
10:00to a value based healthcare delivery
10:02approach away from volume towards value.
10:05And I said this emphatically
10:07because everybody I talked to is
10:08telling me that and when I had my
10:10one chance to sit in the White
10:12House and opine on that topic,
10:14that's what we all said.
10:15So it must be true.
10:17And now 1516 years later,
10:20we are still very much a volume
10:22based healthcare delivery system
10:24and you've written a lot about
10:25this and I'm just wondering what
10:27your thoughts are as to what
10:29might be the trigger to help us
10:31really make more of a move toward
10:34population health improvements,
10:36value based care as opposed
10:38to a volume based system.
10:40Yeah, it's a great question.
10:41I mean when I was in medical school was
10:42when the Affordable Care Act was passed.
10:44And so I very much bought into
10:46the idea that valuebased care,
10:48accountable care organizations,
10:50all these changes in the
10:51healthcare delivery system,
10:53we're going to solve healthcare in some way.
10:55And if anything over the past 10 years I've,
10:57I've just recognized the need for humility
11:00when when you approach an enormous,
11:02you know several trillion dollar
11:04industry and and think that there's
11:05going to be one solution that that
11:07that moves us in the right direction.
11:09You know, I think you and I have
11:11talked about the fact that you
11:13know valuebased care seems like an
11:15important part of the solution.
11:17I mean the alternative of having only
11:20fee for service medicine has gotten us
11:22to kind of the place that we are now.
11:25On the other hand,
11:26you know you really have to squint to
11:28look at the successes for valuebased payment.
11:30I mean,
11:30there are some certainly successes,
11:33but the challenges of measuring quality,
11:35of incentivizing things at a
11:38national level are are astronomical.
11:41And so you know a lot of this comes
11:44back to the idea for me at least,
11:46of approaching these things with humility,
11:49having pilot projects,
11:50creating the evidence base through
11:53probably randomized trials of
11:55these policy interventions before
11:57you roll them out more broadly.
11:59And and you know,
12:01in a way it's a good lesson that I
12:04think there has been some progress
12:05but but certainly nowhere near,
12:07I think what I thought was going
12:09to be the case in 2009 or 2010
12:12whenever we started on this journey.
12:14So,
12:14and Speaking of humility,
12:16your writing is infused with humility.
12:19Like you talk about things without
12:22judgment and you're you give people the
12:26substance to to think about tough topics.
12:29And I'm wondering,
12:30in a time where misinformation and
12:33even disinformation is so pervasive and
12:36everywhere around COVID, to this day,
12:39the amount of misinformation that is
12:42believed to be fact everywhere is so deeply
12:45entrenched in a part of the population.
12:48But you will continue to
12:51put out deeply thoughtful,
12:53lengthy pieces that require
12:54an enormous amount of effort.
12:56Trying to push back on that,
12:58Can you tell us a little about both from
13:00your writing as well as from your research,
13:02What can we do to counter the the
13:05epidemic of misinformation out there?
13:08Yeah, It's another great question.
13:09I mean, I think the first thing to say is,
13:12you know, one of the reasons that
13:14I love writing is because I I
13:15always feel it takes me to a more
13:17thoughtful place than where I started.
13:18So my first inclination is always
13:20something that is more judgmental
13:22than I would like it to be.
13:23It's less, it's more simplistic
13:26than I think it needs to be.
13:28There's a lot of sloganeering that we
13:31hear and and and infuse my thinking.
13:33And then over the course of weeks or months,
13:35when you're putting together a a piece,
13:37you're talking to people that
13:38are affected by the issue.
13:39You try to understand both sides of it.
13:42I always feel like I I end up,
13:44you know,
13:44whatever version ends up on paper
13:46is much smarter than than than
13:48whatever version starts in my mind.
13:50And so that's,
13:50that's one of the reasons that I love it.
13:53You know, the idea around
13:54misinformation I think
13:54is both old and and new.
13:56I mean this information yellow journalism,
13:58these things have been around forever.
14:00And in a way we're better suited to
14:03address these things because the ease
14:06with which we can access true information.
14:08Now the question of like how do you
14:10determine what is true and what is
14:12not true in a world where motivated
14:14actors want to spread mistruths
14:15is a really challenging one.
14:17And I think it's going to get more
14:19challenging in a world where large
14:21language models like chat GB T are able
14:24to drop the cost of misinformation to zero.
14:27You know if in the past a, you know,
14:30non state actor or an adversary
14:31wanted to meddle with a US election,
14:34we actually had to have people coming up
14:37with misinformation and putting it out
14:39there now you know the cost of doing that.
14:42It requires no people essentially
14:44and it requires no money.
14:45The other thing that I want to point
14:48out is I think we we think a lot about
14:50misinformation as a function of social media.
14:53But there are traditional media
14:55organizations that are on cable news
14:57that do much more and have broader
15:00viewership that also contribute
15:02to the spread of misinformation.
15:05I don't think anyone has,
15:06you know, a real solution to this.
15:08I think the surgeon general has put out,
15:10you know,
15:11reports on the effects of social media
15:14as well as calling misinformation
15:16a public health issue.
15:18I think some of it has to do with media
15:20literacy and starting early with that,
15:22you know, in elementary school,
15:24in middle school,
15:25helping people understand the sources
15:27that are that are trustworthy and
15:29those are that are less trustworthy.
15:31I think having you know,
15:33one of the reasons I like doing what
15:35I'm doing is because I think it is
15:37important for people have voices that
15:39they trust and that they can go to
15:41and that help them tune out and and
15:43and sift through all the information
15:45that exists because there's more
15:46than any one person can go through.
15:48But if you,
15:49if you feel like you trust a few
15:51institutions and a few individuals,
15:52maybe you can get get get kind of
15:54most of the way there in terms of
15:56putting together a coherent picture
15:57of the world. So
15:59you're also a new father and that
16:03changes the way you look at the world.
16:05I mean, for anybody who's been a parent,
16:08it changes how you look at the
16:09world and how you think about and
16:11even the questions that you ask.
16:12And you mentioned the certain generals
16:14report on the impact of social
16:17media on youth and adolescents.
16:18And I'm wondering,
16:19does that start to inform what
16:21you want to write on?
16:23Have you already started to formulate
16:25your own thesis on what your children
16:27should and should not be exposed to?
16:30How is that change your world?
16:31But most of the
16:32way that's changed,
16:32the way I see the world is,
16:34is through kind of bloodshot
16:36eyes after sleepless nights.
16:38So that's the first thing I think,
16:40but the, you know, I think
16:45so in one way.
16:46I'm I'm grateful for the time my my
16:49children are at one and almost three now.
16:51And so I I feel badly for the half
16:54generation before for before mine,
16:57because we really did not understand
17:00how problematic the always onlineness
17:02of growing up in an environment
17:04where all your information
17:06comes from the digital world.
17:08You're always comparing yourself
17:09to people not in your immediate,
17:12you know, school or environment,
17:13but people who are glamorous somewhere else.
17:16The expectations that we put on people
17:19have taken it an enormous toll on
17:22the mental health of of teenagers.
17:24I think because of the good
17:26research and the journalism,
17:28the advocacy of people,
17:29people are starting to understand
17:31that this is an enormous problem
17:33and starting to take steps.
17:34I think you know,
17:35at least the way that I approach
17:37or will approach my, you know,
17:39when my children are of the age
17:40where they're using social media,
17:42I think it'll be a much different
17:44approach than people took in the past.
17:47You know, I think we,
17:48you know what we're trying to do at least is,
17:50is make seeing people in person cool again.
17:53I mean that that feels like
17:54the the most important thing.
17:56I mean I've never met anyone.
17:58Maybe you aside, how we that I've
18:00liked more online than than in person.
18:02Everyone is a less good
18:05version of themselves online.
18:07They're snarkier.
18:07They put people down.
18:09They are less thoughtful in
18:10the way that they engage.
18:12And so I think, you know,
18:13it's not like you can wave a
18:15wand and and make this happen,
18:16but I think the more we
18:18spend time with one another,
18:20the better.
18:21And that also gets back to
18:22the misinformation point,
18:23which is the reason that
18:25misinformation can thrive is
18:26because people are mistrustful of
18:29institutions and people around them.
18:31And so the more you are able to engage
18:34with people in a 1 to 1 interaction or
18:36A1 to several interaction the better.
18:38I mean Mass General where I where
18:40I trained during the pandemic,
18:41they started doing virtual town
18:43halls for vaccine misinformation
18:45and they would have,
18:46you know 50,
18:47maybe 100 patients who were patients
18:49of the of the Mass General and
18:51they would host these town halls
18:53and you know they didn't do some
18:54type of evaluation of that program.
18:56But I have to assume that that
18:58type of trust building in one's
19:01community goes a long way to to
19:04making sure that you have the trust
19:05you need to address the next crisis.
19:08And and Speaking of that,
19:09so we're at a point right now
19:11where as I mentioned Mandy Cohen or
19:13graduate of just about 20 years ago,
19:15now maybe 18 years ago is nominated
19:18to be the head of the CDC.
19:20And you know that is one of the
19:24hardest jobs in the country right now,
19:26despite the fact that it was led by
19:29an evidence based infectious disease
19:30physician who is deeply committed to the job.
19:33Trust in the CDC is lower than it's been.
19:36Trust in our institutions are really lower.
19:40When you're writing your pieces,
19:43do you, do you think about what
19:46advice can you give us as citizens,
19:49as people who work in medicine,
19:51about how do we specifically rebuild
19:53trust in the institutions themselves,
19:55in Yale, in Yale, New Haven Hospital,
19:58in Cornell and so on?
20:00Yeah. I mean, I think, you know,
20:02we often ask, you know,
20:03how do we rebuild trust?
20:04And I think that the first kind of
20:07thing I always think about is is,
20:08you know, gaining trust requires being
20:10trustworthy and being a trustworthy actor.
20:12And and so, you know,
20:15focusing on that is kind of the first thing.
20:18And I think one of the.
20:19You know, there were a number of
20:22stumbles obviously early in the
20:23pandemic from the administration
20:24and the CDC and other public health
20:27leaders that that were challenging.
20:28I think throughout the pandemic.
20:29I mean communication was a really,
20:32you know,
20:33difficult thing to do and I'm not
20:36saying that that that it's easy.
20:39I mean anytime there's a fast moving
20:42public health crisis where the data change
20:44from day-to-day and from week to week and
20:47what was right before is not right now,
20:49that is an incredibly difficult
20:51period in which to to communicate.
20:54I think acknowledging the
20:56uncertainty is really important.
20:57I think acknowledging that
20:58this is the first draft,
20:59this is our best effort at at
21:02putting out what we understand
21:03to be where the evidence is,
21:05I think is really important.
21:08But, but you're right,
21:09I mean trust in institutions and
21:11in public health agencies has has
21:13kind of cratered over the past,
21:14I guess 50 years,
21:16but particularly during the pandemic.
21:17And so it's a,
21:19it's a really challenging thing
21:21to try to reverse.
21:22I know Rochelle Wilensky,
21:24the previous director put in place I
21:26think four or five principles to try
21:28to regain the trust of the public.
21:31They're all things that sound really
21:33good in theory that you can't argue with.
21:35But whether or not they translate
21:37into concrete change, I think,
21:39you know Mandy and others will.
21:40We'll have to see through.
21:42When you look back at what you've written,
21:44actually quite a lot.
21:45I mean, if people go and look at
21:47all the publications you've had,
21:48you've written a lot for somebody
21:50who's effectively 9 years out of of our
21:53school and six years out of residency.
21:55Are there any pieces that you look back
21:57on with any level of regret or are there
22:00any specific pieces that you're so
22:01proud of because you wrote it patiently?
22:03Because I can point to pieces
22:05that were patient,
22:06but I'm just curious what you think of
22:10you know there I mean regret I I think
22:14I probably did the same things that a
22:16lot of other folks did was was more sure
22:18about things that I should have been.
22:21I mean one example that comes to
22:22mind is breakthrough infections.
22:23And I think early on was quite confident
22:26that we would not have the level of
22:29breakthrough and disease that would come
22:31after full vaccination and had written
22:33pieces to that effect and that was,
22:35you know, turned out to be incorrect.
22:37So I think that that that's something
22:38that very clearly comes to mind.
22:39I think, you know,
22:40the pieces that I'm proud of are kind of
22:44deeply reported pieces about what people,
22:46individual people were going through.
22:48I think that is where I felt like some
22:49of the writing was distinguished.
22:51And so I I did a profile of a trauma
22:55surgeon who had been through kind of
22:57months of intense ICU care during the
23:00the midst of the pandemic and developed
23:04PTSD and had a really challenging time.
23:06And I think it's not that all clinicians
23:08who went through that experience
23:10had the level of PTSD that she did,
23:13but I think it resonated and it gave
23:15some voice that leads to the fact that
23:18a lot of clinicians put themselves in,
23:20in challenging situations or were
23:21put in in challenging situations,
23:23not always with the level of
23:25institutional support that they deserved.
23:27And so.
23:27So that's that's one that kind of
23:29comes to mind in terms of something
23:30that that I was proud of.
23:32I want to open it up for questions
23:34and just put your hand up.
23:35If you have a question,
23:36I'll go and just tell us
23:39your name so that we it was
23:51well accepted by the
23:52community and by my parents.
23:54And in questioning how did
23:55we did we have more trust?
23:57If so how did we lose the
23:59trust from years ago?
24:01Yeah. You know, I always thought
24:03that vaccine hesitancy had to do
24:05the fact that we didn't have,
24:06like younger people today didn't
24:09have to contend with polio.
24:11And so it's very easy to talk about a
24:14disease that seems abstract and and
24:15not want to take the vaccine for it.
24:17That also turned out to be very wrong.
24:19You know, you could see your
24:21neighbors dying and and still
24:22have a level of vaccine hesitancy
24:24that that kind of appalled me.
24:27So the first part of the answer is that yes,
24:30I mean trust.
24:31If you look at trust in medical leaders,
24:33for instance,
24:34in the 1970s around the time of Watergate,
24:37I mean 75% of the public said
24:39that they had very high levels of
24:41trust in healthcare institutions.
24:42That number today is in the 20s or 30s.
24:45So that is true of the media.
24:47That is true of government.
24:49You know,
24:50I think there's a lot of factors
24:51that are involved in that.
24:53One is simply the fact that we have
24:55access to many other sources of
24:57information than doctors or healthcare
24:59institutions about our health.
25:01And so in the past if you wanted
25:02to know something,
25:03most people would would have a
25:05provider of some sort that would
25:07give them that information.
25:08Now you look online, you,
25:09you know talk to your your friends,
25:11you have social media,
25:12all sorts of things contribute to
25:14the way that you, you, you, you,
25:17you understand your own healthcare.
25:19I think another part of it is
25:21back in the 70s and 80s things
25:23like conflicts of interest weren't
25:25weren't as widely recognized.
25:26I mean, I think in the 90s and early 2000s,
25:28people started to think about
25:30healthcare leaders differently,
25:31in part because they felt that
25:35at least some proportion of them,
25:37but their care was dictated by
25:39the incentives.
25:40I think there's been a tremendous
25:42amount of corporatization of medicine.
25:43And so in the past, you know,
25:46there was, I mean now private equity
25:48institutions are buying nursing homes.
25:50You can imagine how well that
25:52that's going to go.
25:53But, but more broadly,
25:54there's been a tremendous
25:55amount of consolidation,
25:57massive healthcare systems.
25:58You don't have your local,
26:00you know mom and pop doctor
26:02that that you go and see.
26:05And then I think that the final thing
26:07I'm there's many other things probably,
26:08but the big one that comes to
26:10mind is the rising of healthcare
26:11costs and the the burden,
26:13the financial burden that
26:14it places on people.
26:15It's very hard to trust the system
26:17that with one illness will put you
26:19into bankruptcy and you don't have,
26:22you don't feel like you have
26:23protection against that.
26:24Is that the fault of insurers?
26:25Is that the fault of the the providers,
26:27Is that the fault?
26:27I mean people don't really care,
26:28right?
26:29I mean the fact is most Americans
26:31can't pay a an unexpected medical
26:34bill and if they have to go
26:35fill a drug at
26:36the pharmacy that the doctor prescribes,
26:37it's going to put them out for a while.
26:39So some some some contributors I think
26:46plus 63 for the medicine when
26:48I trained, all reasons why
26:56I did. But right now there's so few
27:00people seem to have the primary care
27:02doctor and we are doing nothing as
27:06the profession really to increase the
27:09number of primary care doctors and
27:20the intern medicine doing the
27:29best we could do for them for a long time.
27:31Now each number of people are going to
27:35urgent care to be a doc and I I see
27:38even though back in 2020 they tried to
27:41increase salaries a little bit the gap
27:48gets wider and wider between primary
27:50care and the sub specialists and
27:52no matter what you tell medical
27:54students and they can figure out
27:56where the money is better than I did.
28:08Yeah,
28:12I would love to hear your thoughts
28:14how we I mean I I myself am
28:17a general internist so I also
28:19made the mistake that you did.
28:21But a couple things,
28:24I mean one is the the large and
28:26increasing gap between the pay for
28:28subspecialties and for general internists.
28:30Two is the the status that is afforded,
28:34you know different specialties.
28:35I mean if you're if you're you
28:38know a star subspecialist often
28:39you are viewed with higher status
28:41than if you're not don't have that
28:43level of training or you you are a
28:47general insurance like like myself.
28:49I think I see things potentially
28:52starting to change in some ways.
28:54I mean one you know in in my class there
28:56were a number of people who ended up
28:58going into general internal medicine
29:00and in part because they wanted to
29:01do other things in addition to it.
29:03And so that that that is that
29:05is one challenge that a lot of
29:08people who now go into general
29:10internal medicine are also doing,
29:11you know mostly academics or startups
29:13or or whatever whatever it might be.
29:18You know, I don't know
29:19how to reverse the trend.
29:21I mean the administrative burden is,
29:23is astronomical on on on
29:25primary care doctors that the
29:28pay is not super high, right.
29:30I don't know how how would you? I
29:32mean I think the incentives don't align.
29:34I mean right now we've set up a system
29:37that incentivizes doing volume and doing
29:41procedures and unless we really fix that,
29:43we're not going to fix everything else.
29:45Having said that, there is 10s of
29:48billions of dollars being invested
29:50in startups including Devoted Health,
29:53City Block Health.
29:54Amazon just made their acquisition
29:55and Aetna made their acquisition.
29:58So we're seeing billions being
30:00invested in primary care in an
30:03effort to disrupt the system.
30:05But the underlying economics
30:06of it haven't really changed.
30:08So I'm not sure that we're any
30:11closer than we were ten years ago.
30:13But I'm definitely, you know,
30:14when reporters ask me about what
30:16Amazon's doing, what CVS is doing,
30:18what City Block, Alidate and so on are doing,
30:21I always say I'm rooting for all of them.
30:23Like I I want them to succeed,
30:26but there's not been the evidence yet.
30:27As you pointed out,
30:29with the value based healthcare,
30:31you have to squint to see the
30:34successes for the moment.
30:36There was a question there.
30:36And then you Yep,
30:39Can you comment on the fact that we all
30:45have our desired and trusted sources
30:47of information and how do we reach
30:50people who have different sources?
30:52I had, for example,
30:53a friend during the pandemic,
30:55the only one who would not get vaccinated.
30:58And I felt as a Yale Medical school graduate,
31:01perhaps she was not a physician
31:03to listen to me. And she did not.
31:05And explain to me that she had
31:07her quote UN quote own sources and
31:10concerns about the history of the
31:13autism and vaccines which has been
31:17you know you know compudiated and
31:19yet you go to the correct sources.
31:22And I will not say what they are
31:24but I think we all do and I think
31:26we all know the people remote them.
31:28So there are people I feel like
31:30we live in a in a country.
31:33I live in a different world than the
31:35world that this person does because
31:37the information they receive and and
31:40don't in my and and critically assess
31:42and I was and then she is not the only one.
31:45I've had patients say this to me and
31:46where I finally have to interrupt
31:47them and say
31:51need to agree to disagree
31:55on with my being able to take care of you.
31:56Yeah. I mean I think you know one one
32:03part of this is the fact that people
32:07don't make decisions based on careful
32:09analyses of the risks and benefits.
32:11Most of the time most of our
32:13decisions are socially determined.
32:15You know the people,
32:15what the people around us are doing,
32:17how our community feels about an issue,
32:19what our family and friends have done.
32:21And so a big part of this,
32:22I mean one thing to note to to the
32:24earlier question is that trust in
32:26medical leaders broadly has fallen,
32:28but people actually have very high
32:30levels and trust of their own physician.
32:31So if you have your own physician
32:33off and that's that's that's
32:34a really important part of it.
32:35But even in this case,
32:36when people have different types of
32:38information sources that you feel like
32:40you're not able to to get around,
32:41I mean part of that,
32:42the reason is that they're not analyzing,
32:45you know,
32:45the number needed to treat in the
32:47way that that that we might be 1
32:49concept that I found very helpful
32:50is this idea of trusted messengers.
32:52So every community has people who
32:54they look to and they may look
32:57to different different sources
32:58than than we look to.
33:00I wrote an article recently
33:01about Francis Collins,
33:02the outgoing NIH director,
33:04and he's an evangelical Christian.
33:06And so a lot of what he wants to
33:08do in his post directorship life
33:10is focused on this very issue.
33:12So he's doing a lot of work
33:14with church groups and pastors
33:15and going into communities.
33:17He's he said he wants to spend
33:19whatever you know credibility and
33:21capital he has gained over this
33:23long career as the scientific mind
33:25trying to go into the communities
33:27that he feels are his own communities
33:30evangelical Christians and trying
33:32to increase trust in public health
33:35and vaccinations And so are there
33:37a lot of trusted messengers in some
33:38of these communities probably not.
33:39But I think that is the most
33:41effective intervention that I've
33:43that I've ever come across.
33:45David. Yeah I'm David Greene class three.
33:49I want to get your thoughts on the
33:51disturbing trend that we're seeing
33:56largest most eligible population.
33:59Of course, we're seeing the
34:04hugest number of primary cares
34:06going to falls fears medicine,
34:08while the population of patients and that
34:20looks like increasingly that's
34:21becoming the shape of the future.
34:24So I want to see what
34:25your thoughts are on that.
34:26The shape of the future.
34:28Yeah. I mean, in a way when
34:29I've talked to people who
34:31do concierge medicine,
34:31I mean some of it is financial.
34:33Some of it is at least they say this
34:35idea that they're able to practice
34:36the type of medicine that they want
34:38to practice that they don't feel the
34:39same pressures to see as many patients
34:42as they as they as they did before.
34:45You know I think we to
34:46our earlier conversation,
34:46I think having a practitioner whether
34:49it's a nurse practitioner or a
34:51Doctor Who is your primary point
34:53person into the healthcare system is,
34:55is incredibly it is one of the
34:57most important things that that
34:58one can have for their health.
35:00You probably know the space
35:01better than I do in terms of
35:03concierge medicine And and
35:05yeah, I mean concierge medicine
35:06had like a peak very early on and
35:08then it's sort of modified itself.
35:10That the example of concierge medicine
35:12that worries me the most right now is
35:14and maybe I'm going to get it wrong,
35:16is 1 medical that was on the West
35:18Coast that was acquired by Amazon.
35:19But that was a level of of a primary
35:24care pay your subscription and
35:25you can get access to a doctor.
35:28But if you're not a member of that network
35:30and you're not paying the subscription,
35:32and then you're relegated
35:33to fending for yourself.
35:34And So what it does is it provides a really
35:37good level of care for those that have means.
35:39We all have means,
35:41but there's a huge swath left behind.
35:44And quite frankly, to me,
35:46one of the biggest concerns is that we've,
35:49you know, we're drowning the frog.
35:50We're just acclimating to the idea
35:52that we do have two tiers of a
35:54system right now and that that's
35:56sort of acceptable in most locales.
35:58I mean, you're you're in New York,
35:59which is a great example where you
36:01have a City Hospital system operating
36:03in parallel with private hospitals.
36:06And if you're a poor or underinsured
36:09or Medicaid patient,
36:10you go to the city hospitals and
36:12if you have commercial insurance,
36:14you go to Wild Cornell or you go to
36:16Columbia or you go to NYU Langone.
36:19Yeah. And and the other thing that I think
36:21people don't talk about enough is that
36:22the city hospitals and public hospitals,
36:24they actually subsidize the the,
36:26the more private oriented hospitals,
36:27right, Because they,
36:28they take patients who otherwise would
36:30have to be treated in those institutions.
36:32And so I don't think that's
36:34something that people have fully,
36:35fully grappled with. Yep.
36:38I'm Carl Mann C and Gro 73.
36:40Tell me the difference between valuebased
36:43medicine and riskbased medicine.
36:47There's a lot of overlap between
36:49those two things. I mean, so the,
36:51the basic idea behind value based
36:53medicine is that you tie payment to
36:56some measure of of quality and there
36:59are different ways to go about that.
37:02And so in the kind of initial
37:05version of that, you might just tie
37:07a regular fee for service payment.
37:08So you do it, you do something
37:10and we're going to pay you and
37:12we're going to adjust that payment
37:13slightly based on the quality or
37:15the outcome of that procedure.
37:17Let's say that's what the the
37:20MIPS program for instance,
37:21the Medicare MIPS program is focused on.
37:23There's a lot of controversy about
37:26whether it does anything that is
37:28that that is helpful for patients.
37:30The on the other end of the
37:32spectrum is kind of full risk,
37:34meaning you as an organization or provider
37:37care for a population of patients upfront.
37:42We will give you the, the,
37:44the what we expect this population of
37:48patients to cost and you get to functionally
37:51keep the difference between what we
37:53paid you and what you end up spending.
37:55And so you're taking the
37:57risk for that population.
37:58So if you come in over that,
37:59if you spend you know $15,000
38:01a patient instead of 10,000,
38:03you eat that cost.
38:04If you spend 8000 and you know and
38:07and we gave you 10,000 per patient
38:09then you you benefit from that.
38:11You can see how this is challenging and
38:13in one way in that it may incentivize
38:16people to do less for for their patients
38:18because they want to save money.
38:20So there are some guardrails around that
38:22you have to meet certain quality metrics.
38:24You know the ideally the outcomes
38:27for those patients are are measured
38:29very closely and then there's the
38:31additional challenge is the amount
38:33that you initially get paid for
38:35that group of patients depend on
38:37how sick those patients are, right.
38:38So if you're a young person
38:40with one comorbidity,
38:41you know you're not going to cost
38:42as much in theory as someone who is
38:44much older with many comorbidities.
38:46So there's the incentive on
38:48the part of the providers,
38:50people will say or the insurers to
38:52make their population look sicker
38:54than they actually are or make
38:56them look as thick as possible.
38:58So you can see why value based
39:00care in theory.
39:01At the beginning of this,
39:02we talked about how we felt it
39:03was really the right thing to do
39:05and I still think generally it
39:06is the right thing to do.
39:07But there's all these ways
39:09to game programs that make it
39:11really challenging in actuality.
39:13And and to that point I would just
39:16say like they were series of lawsuits
39:19including one against Cigna earlier,
39:22a late in last year,
39:23I think November of 22.
39:25And it just highlighted for
39:27me how these companies,
39:28you know if you want to make them blameless,
39:29you can just say that the incentives
39:32line up for Cigna to want to elevate the
39:34risk rating of their patient population.
39:36So they could collect as much money as
39:39possible and ideally they want to spend
39:41as little as possible on those patients.
39:43Ideally, it's not exactly what
39:45you would describe if you were
39:47talking about building a a value
39:49based healthy healthcare system.
39:51But the theory
39:52is you know you have this population
39:53of patients, we're going to give you
39:55this much money and you figure out
39:56how best to manage these patients.
39:58So in the past you know you only get
40:00paid if the patient actually comes
40:01in for the doctor's visit and then
40:03you bill them and then they now
40:05let's say you can do telehealth,
40:06you can call them,
40:07you can send someone out to their home.
40:09This is the theory that you can
40:10be more creative in the way that
40:12you care for these patients.
40:23I
40:28would just say about Kaiser,
40:29which is always I think I
40:30agree with you about Kaiser.
40:31Everything I've read, I talk about
40:33it a lot when I teach my courses.
40:35But Kaiser has the luxury of
40:37dealing with a commercially insured
40:38population and only takes on Medicaid
40:41patients to the extent they want to
40:43take on Medicaid patients and same
40:45for Medicare Advantage. So it is,
40:48it is a different entity and animal,
40:50it's an integrated system.
40:51But I agree with you.
40:52Like if you asked me what I would
40:54prefer to have anywhere in the
40:55country would be a Kaiser model now.
40:57And of
40:58course up until two years ago,
41:00the CEO was Yale 72.
41:03That's right. That's right. Let
41:04me go over here and then I'm
41:06going to come back around.
41:07I think him first and then you Ed
41:10Weaver, Class 93 probably value based
41:17care. What assumptions did you
41:19have then that you realize now
41:22might not have been correct that
41:24altered how things turned out?
41:26Yeah, I think, you know,
41:27we all were drinking the kool-aid
41:30about how successful Kaiser,
41:32Geisinger, even Cleveland Clinic,
41:33like each place we would talk about being,
41:37look how successful they are.
41:38They can do it.
41:39Why can't we do it anywhere else?
41:41And there are a lot of cultural
41:43differences between Kaiser in, you know,
41:46Southern and Northern California
41:48and Kaiser putting it in Texas or
41:51Kaiser putting it in Pennsylvania.
41:53And I think what we've come to realize
41:55is the culture among physicians and
41:57the culture on patients has to align
41:59with the system we're talking about.
42:01So it's a lot easier said than
42:03done because I was one of those
42:05people who thought like,
42:06why can't we just recreate
42:08Kaiser in other places?
42:09But easier said than done.
42:11That was probably my single biggest point.
42:13I don't know if you have other thoughts.
42:14I was going
42:14to ask you why you feel.
42:16I mean is it just the cultural
42:18exploitation that's really hard.
42:19I mean Kaiser's tried to expand,
42:21if not done very well,
42:23The Mayo Clinic has tried and in some
42:25places and still have some institutions.
42:28But is it a matter of you can't
42:30just stick the name of this
42:32amazing institution on some
42:33other place somewhere else?
42:34And or like, why?
42:35Why is it so hard to expand? I
42:37think in Kaiser's situation is that the
42:40population actually accepts that care is
42:42going to be delivered a different way,
42:43That you don't deserve an MRI
42:45every time you twist your knee,
42:47that you don't have to go into an expensive
42:51emergency room every time that you have,
42:55you know, an ankle pain.
42:56I mean, I work in the emergency
42:58room as a radiologist and I read
43:00histories basically on every single
43:01study and then blown away by what
43:03we call an emergency right now.
43:05Kaiser knows how to triage that.
43:06Kaiser knows how to use their own supply
43:11side limitations on care to be able to
43:14deliver the most important care of the
43:16people that most acutely in need and
43:18be able to put people on a schedule
43:20for care if they're later in New Haven.
43:22If you were to tell somebody,
43:24come back in in three weeks
43:26and if it's not better,
43:27then we'll we'll see you again.
43:30They would find a different doctor to see,
43:32wait till you come to the
43:33Upper East Side of New York,
43:35right, Right. Yeah. Yeah.
43:36There's another question here and then
43:38I'm going to go back there. Yep. So
43:41as
43:48physicians, we basically do two things,
43:50right. We use our cognitive abilities
43:53and we also comfort patients.
43:55And it seems to me that it's quite
43:59clear that machines are going
44:00to be able to do both of those
44:03functions much better than us. As
44:15I guess I would question the premise of
44:18the question in that do you think that
44:21people will feel comforted by machines
44:23in the same way they do as humans
44:39are going to have more machines
44:43as friends
44:56as they are going to have. Yeah.
44:57It's I mean it's a really I don't
44:58think anyone knows the answer to this.
44:59I do know that a lot of people who
45:02work on a I place the the likelihood
45:04that A I will make humans it's extinct
45:07somewhere between 10 and 20% and so that.
45:09So it's a very scary kind of
45:11thing going forward.
45:13You know I used to think or I I my my belief
45:16still is I I kind of have three jobs.
45:17I write and I do research and I and I
45:20practice medicine and I do think that
45:22my first two jobs are most amenable
45:24to being replaced by by an A I like,
45:26I there's not.
45:26I do think probably in 10 years an A I
45:28can write an article for The New Yorker.
45:30You know like I I,
45:31I I think that's probably true.
45:33Before I talked to you I felt like
45:36maybe my doctor job was safe but
45:38but maybe I'm wrong about that.
45:40I don't know.
45:41I mean, I, I, I,
45:43I hope that there's still not just
45:47not just the comforting role,
45:49but there are other parts of medicine.
45:52I mean I look at a lot of the patients
45:54that I care for in the hospital and I
45:56think about how what do they often need?
45:58I mean do they do they need the
46:01diagnostic acumen of an A I or do
46:04they need a lot of them need nursing
46:07care and support in that way.
46:09A lot of them can't use technology.
46:11They they you know they're not
46:13able to themselves engage with it.
46:15I do think medicine at least parts of
46:18it are safer than than than maybe we
46:21we we were talking about right now.
46:23I I wrote an article recently about a
46:26I psychiatry and the and the potential
46:29for chat bots to deliver psychiatry
46:31and explored a lot of these issues.
46:33And my sense is that for the kind of
46:37routine things that that we do that
46:41are protocolized that yes A I will
46:44probably replace those functions.
46:46But for I think for a lot of the
46:48more sophisticated things that we do
46:51that require a certain knowledge of
46:54the real world that's further off.
46:56But if we were talking six months
46:58ago before ChatGPT,
46:59I would have we were you know I
47:01wouldn't have any idea what to to say.
47:03So I don't know
47:04I was told 10 years ago that
47:06radiologists would be replaced
47:08by now and they haven't been.
47:10So I think things are,
47:12even though it feels really fast
47:14right now with ChatGPT and the
47:16movements in that direction,
47:18I still think we're going to play a role.
47:21It's just going to be a very different role.
47:22I mean it would be ideal if it be
47:24if there was a reliable way in
47:27which we could harness that power
47:29for people to get the answers that
47:31they want from us but that aren't
47:34really at the top of our license.
47:37But get those answers by going
47:39online and feeling comforted by
47:41that and using us for the top of
47:44license intellectual inputs we have.
47:46But how is it so pathology
47:49and radiology were or you know have been
47:51talked about for a decade now, right.
47:52I mean you can a I can figure
47:55out a cat versus the dog.
47:56They can figure out whatever it
47:57is that you you try to figure out.
47:59But does a I play any
48:01role in your world.
48:03What role does it play right
48:04now in your. So it helps.
48:06It helps with triaging of exams.
48:08So it will pick up most
48:12intracranial hemorrhages.
48:13It'll pick up most fractions
48:14of the cervical spine.
48:16It's now doing a good job
48:18picking up pneumothoresis,
48:19rib fractures,
48:22pulmonary emboli,
48:24large vessel occlusion in the brain.
48:26You go to work,
48:27does it, does it present these,
48:29it presents these you and then use
48:31triaging those things.
48:31For me, it's telling me this
48:33is a case we think is positive,
48:34so I'll put that case at
48:36the top of my cue to read.
48:38But then it also is just an extra
48:40set of eyes on every single case.
48:43So quite honestly,
48:43I used to joke with the residents
48:45that it's your job to look for rib
48:48fractures on a chest CT because
48:49I don't want to spend all my
48:51time looking at rib fractures.
48:52It's not a particularly top of license issue.
48:56But now if the A I app says
49:00there's no rib fractures,
49:01I'm sort of like there's no rib fractures.
49:04So it is slowly giving us the
49:06comfort of an extra set of eyes.
49:08Now at some point it's going to
49:09be better than me and at some
49:11point it's going to be able to
49:13figure out how to integrate the
49:14findings into a diagnosis,
49:15which it does nothing of the sort right now.
49:19That's when I think we'll
49:20see real fast change.
49:21Are you as confident that 10 years
49:24from now they'll still be as many
49:26radiologists as there are today or no,
49:27There will be a smaller number
49:29of radiologists relative
49:30to the number of studies.
49:31But that's been going on for a long time
49:32and I think it's going to continue happening.
49:34Technology has allowed us to read,
49:37I read 120 to 150 studies
49:39on a shift right now.
49:41There was a time, you know,
49:4320 years ago where if I was reading 30 or 40,
49:46that would have been a lot.
49:47So that's been going on for a long time.
49:49This is just another
49:52technology accelerating that.
49:53There were a lot of questions.
49:54Yep,
50:06the first one, chat GB T3I think failed,
50:09but GB T4 can pass with 90%,
50:12which is better than nine out of 10 docs.
50:17The question in my mind
50:18is, is I I think we assume that G,
50:20PT5 and six will be either
50:23linearly or exponentially better.
50:25It's not clear to me.
50:27I'm not, I'm not a computer scientist.
50:28Whether that's that's true or not.
50:29I mean, there are some people,
50:31I think who have already
50:32indicated like Sam Altman,
50:33the the CEO of Open AI,
50:35that they may be getting kind of to
50:38the limits of what they can achieve
50:39by just putting more and more
50:40data into these types of models.
50:42And so there may be different
50:43things that need to happen for it
50:45to actually get to the next level.
50:47But but I guess you know that
50:49that remains to be seen
50:51you and then you sorry, I think it's
50:52more concerning that Jack GPT lies
50:56and makes stuff up for no reason.
50:58There's a lawyer that may filed with
51:02the court and forget what the issue was,
51:04doesn't matter, and decided to use ChatGPT
51:14chat. GPT started out
51:16with some regional stuff,
51:18but then made-up judges and opinions
51:21and citations that never existed,
51:24and within citations and citations,
51:28within citations and citations
51:30that we had a thin air,
51:32not just trouble for.
51:38And then another
51:46governors of South Dakota for South
51:49Dakota magazine and did a fine thing
51:54on the oldest one and then for no
51:58reason made-up a youngest governor
52:01and completely BS the whole thing.
52:04And it also created a very
52:08gubernatorial governor,
52:09quintessential governor looking governor,
52:12two pockets with two
52:16pocket
52:23squares. So that makes me very
52:26concerned if the artificial intelligence
52:28is acting a little bit like how
52:33from
52:362001. One issue is that it doesn't
52:38actually think about anything, right.
52:39It just it's like people describe
52:41it as auto correct on on steroids
52:42or auto complete on steroids.
52:44It's just predicting what the next
52:46word should be in a sequence and it
52:48has no idea what it's actually saying.
52:51I don't think that's the way that
52:52these models are are are used.
52:54I mean they there's a model that
52:56basically said that Elon Musk died
52:58in 2018 in a Tesla car crash and
53:01it has tons of information that
53:03discounts that prediction but it
53:05has no idea what it's saying.
53:07I think one question in my mind
53:09is is is it going to is in certain
53:11highstake fields like medicine is
53:13the use of a I going to be like it
53:15is in driverless cars where for a
53:17decade or more we've been talking
53:20about driverless cars and and and
53:22the level of accuracy and precision
53:24you need to like feel very confident
53:27that you're going to let the A I take
53:30over is greater than 99.9% probably
53:32even even if it's better than
53:34a radiologist that reading a scan
53:35or better than a driver at driving.
53:38The the culpability the blameworthiness
53:40that we want to have someone to
53:42blame something goes wrong and
53:44blaming a machine isn't isn't enough.
53:46And so I think that might be one
53:48reason that some of our jobs are
53:51protected for some period of time is
53:52that it's such a high stakes endeavor.
53:54Any mistake is potentially catastrophic
53:56and and we don't want to hand that
53:59over just yet to the machines.
54:43Yeah, I'll take the first one,
54:45you take the second one.
54:46So there was a, there was a a study
54:49published in JAMA Internal Medicine I
54:51think recently that looked at patients
54:53who are asking questions on Reddit and
54:55ended up comparing the responses that
54:57were automatically generated by chat TBT.
54:59And those were that were answered
55:01by doctors and the ChatGPT responses
55:03were both more empathic and
55:04more accurate than the doctors.
55:06Now these are doctors that are
55:07answering random questions on Reddit.
55:09I mean you know,
55:10take it for what what you will,
55:11but it's at least suggestive that that
55:13what you're saying is is correct.
55:15Yeah.
55:15And your point about Kaiser is, is fair.
55:17I mean, I think any supply side
55:20integrated delivery system,
55:21whether you're talking about the
55:23National Health Service of Britain,
55:24whether you're talking about Yale
55:26University Health Services or whether
55:27you're talking about Kaiser on the margin,
55:30the people who are vacillating in
55:32that Gray zone of can I get the care
55:34I think I need or my doctor thinks
55:36I need and you're being told no,
55:38you're going to be distant,
55:39you're going to feel disenchanted by that.
55:40So it's a very real concern,
55:42but it but it's like weight off
55:44of the benefit that flows both
55:46financially as well as delivery wise.
55:49So Yep,
56:02as a surgeon, the surgery is as a
56:09legacy. My father and my uncle were surgeons.
56:11Both graduated here and I came here.
56:13I want to be a surgeon.
56:14I wanted me to do the best I
56:16could from all perspectives.
56:17And I was profoundly
56:18impressed by the faculty here,
56:20surgical and otherwise, that were
56:22pursuing excellence for its own sake.
56:24And their their reward for doing that
56:27was increased fame and writing papers.
56:30But the better they got,
56:32the more work they they got to
56:34do and the same school deal.
56:36But we didn't have any exams.
56:38And that
56:46was all great. And I came out and I started
56:54working in a couple of levels,
56:56community hospitals and a major
56:59University Hospitals affiliated with
57:01Harvard and the surgeons there, all,
57:04you know, they all made a good living,
57:05but they were busy.
57:06And the ones who weren't good
57:08didn't make a good living.
57:09But the way they functioned,
57:11they were aware that they
57:12had to do a quality product.
57:14And even though we were
57:15competing with each other,
57:16we regularly talk weekly go over our
57:19morbidity and mortality and but that that
57:35surgeon has worked that system
57:37has worked pretty well.
57:38You know surgeons do cases that
57:41are indicated and they don't think
57:43they get run out of town and good
57:45surgeons make a pretty good living.
57:46And if people are in a place where every
57:51everybody gets paid no matter what they do,
57:53surgeons tend to not to want
57:55to work that hard.
57:56So you know, I I think the surgeons,
58:11yeah, I think and what
58:12you're saying makes a lot of
58:13sense to me. I mean even in in valuebased
58:15payment systems, there's room for
58:17productivity incentives within those.
58:18So you could envision a system that has
58:21both some element of risk or capitation
58:23and also productivity incentives for for
58:25surgeons or other procedures or for anyone.
58:28A couple of things.
58:29I mean, one is I think Howie once said,
58:31you know, in the decades ago, you know,
58:35people thought that doctors did the right
58:37thing no matter what the incentives.
58:39And now people think that doctors
58:41only respond to incentives. And.
58:43And and I think that's also
58:44incorrect in the sense that,
58:46you know, any quality measures,
58:48I was talking with a colleague earlier,
58:50any quality measure in my view
58:52only measures a very small part of
58:53if a doctor does this much stuff,
58:55a quality measure,
58:56whether you check the A1C or whether you,
58:58you know, did this or that,
59:00measures a tiny fraction of what
59:01we actually do.
59:02And so the idea that we need to
59:05instill professionalism and pride
59:06in our work and that should be the
59:09primary motivator for any doctor, not,
59:11you know, this this small incentive,
59:14this quality measure here.
59:15I think that's that's a really
59:17important insight.
59:18One question I have for you and for
59:21you is the places that you mentioned
59:23where I think Yale and a Harvard
59:26affiliated institution and I have no
59:28doubt in my mind that the Mayo Clinic
59:30and the Cleveland Clinic probably
59:32don't need these types of incentives.
59:34I do wonder if you can standardize
59:36quality through the ethos you
59:38described across the country and
59:41is that true in every pocket of the
59:43country or do you need some type of
59:45incentive system in those places?
59:47I think one of the reasons that
59:50valuebased payment took off and quality
59:51measurement took off and you should
59:53talk about this because you were there is,
59:55you know,
59:55a lot of the Dartmouth studies,
59:57the the studies that came out of
59:58Dartmouth which showed that there's
60:00tremendous variation in the way that
01:00:01people care for people across the country.
01:00:03So if you're in one state or one town,
01:00:06you might be three times as likely
01:00:08to get a cesarean section as
01:00:10someone in the town next door.
01:00:11If you are in another you know,
01:00:13part,
01:00:13you get an MRI for this and
01:00:15you don't get an MRI for that.
01:00:16Some of that might be appropriate.
01:00:17Some of it may reflect
01:00:19underlying preferences,
01:00:20disease prevalence and population.
01:00:22But I think a lot of this work towards
01:00:25quality measurement and standardization
01:00:26grew out of this recognition that.
01:00:29There was wide unexplained variation
01:00:31in practice across the country.
01:00:34Yeah, I mean, I look,
01:00:35I happen to believe that incentives
01:00:37have to work in both directions.
01:00:39We need to be able to meet.
01:00:40We do not want to reach a point where
01:00:44physicians are paid minimum wage, right?
01:00:46We want to be able to put a value
01:00:48on what people are able to provide,
01:00:50and we want to have the appropriate
01:00:52incentives to ensure value to the patient.
01:00:54Quality of care,
01:00:56of cost should be a consideration.
01:00:59It's a very it's it's more than
01:01:01an imperfect system we have
01:01:02right now that's the problem.
01:01:04If we only had an imperfect system,
01:01:06we would be striving to make it better.
01:01:08We have a very deeply flawed system
01:01:10where there are people that are able
01:01:13to extract enormous economic rents
01:01:15and then we rely on very charitable
01:01:17good people to provide care to grossly
01:01:21underinsured and uninsured individuals.
01:01:23And for those of us that think that
01:01:25social justice or equity or anything
01:01:27in terms of Healthcare is important,
01:01:30it it creates a real challenge for us.
01:01:32But I want to,
01:01:33I want to wrap it up because we're over
01:01:35time and and Michael's looking at me there.
01:01:37I just want to thank you
01:01:38first of all for doing this.
01:01:40It's really generous of you
01:01:41to give us your time.
01:01:42I want to thank all of you for joining us.