Podcasts

Improving the Patient Experience

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Unknown Speaker  0:02
On today’s episode we interview Jason hair patient experience coordinator at Glens Falls hospital. We start off by defining what the patient experience is, and then dive into simple ways that physicians can improve their patients experiences. One great example was the next time you’re about to walk into a patient’s room, stop, take a deep breath, and then start the visit. So be sure to listen to the rest of the episode to find out what other easily executed high return on investment actions physicians can take to improve their patients experiences. The ideas expressed in this podcast are those of the interviewer and interviewee do not represent those of our respective employers. This podcast is intended for medical professionals. The information is be used in the context of your own clinical judgment knows in this podcast except no liability for the outcomes of medical decisions based on this information. As the radiologist like to say clinical correlation is required. This is not medical advice. Even though the magical podcasting may make it seem like I’m speaking directly Your ears. This does not constitute a physician patient relationship. You can have a medical problem, seek medical attention. Welcome to Episode Four of the physicians guide to doctoring podcast. We’re here with Jason hare the patient experience coordinator for Glens Falls hospital. I’ve known Jason, basically my entire life. And I’ve always known him as an entertainer. So it seems appropriate that he’s involved in something like this. But Jason, tell us how did you end up in that position?
Unknown Speaker  1:35
Sure. Well, first of all, Brad, thanks for having me on the on the podcast. I’m excited to chat with you about this today. So I’ve been in the patient experience coordinator role for just under a year at Glens Falls hospital. I’ve been in healthcare now for almost 20 years. I started off in credentialing and medical staff office at a hospital for special surgery in New York City. From there, I moved on to the to the health care tech side of things the for profit side, I worked at Zach Doc, I helped run their their customer service division for about six years, and recently moved from New York City to beautiful upstate New York, and was really excited to get back into an area where I would have more direct contact with patients in a very direct healthcare setting. And it’s, it’s a, it’s a great role. It’s a great role to have.
Unknown Speaker  2:30
So this is something that’s really rapidly emerging in the healthcare field where we’re recognizing that something that we’ve been lacking for a long time is, is customer service. And we’re taking cues from industries that have that have done that well. So, you know, I think that your role is really hugely important. And so I think we should explore what that what that entails. But you’d mentioned before the podcast that we should define What the patient experience is, which I think belies the fact that we, as physicians may or may not have the same perspective as the patient on what this experience is. So let’s, if you could define that.
Unknown Speaker  3:13
Yeah, absolutely. So I think you’re absolutely right that this is more of an emerging thing now and it does have ties to customer service because, you know, like it or not, our patients are consumers and they have choices. There are lots of sites you know, like Zach Doc, which I mentioned health grades, vitals, you know, whether those reviews of of providers are fair or unfair, they’re giving patients a voice and they’re giving them a choice in their, in their, in their healthcare. So patient experience does have relations to customer service, I think, what is a frequent misconception of patient experience? Is that is that it’s patient satisfaction. I don’t think they’re the same thing. I think that patient experience is not actually about happiness because we’re in health. care. We work in doctors offices, we work in hospitals, we can’t always make patients happy. And that’s okay. There are there’s no real universally recognized definition of patient experience. But one of my favorite ones, which was was said by Patrick Ryan, who’s the CEO of Press Ganey, who I’m sure that company I’m sure is familiar to some of your listeners is what he says is that the patient experience you know, it’s not about happiness, what it is about. It’s about patients. And I’m going from memory on this here, but it’s about patients being cared for communicated with respected and having their care coordinated in such a way that they can get the best possible clinical outcome for whatever their circumstances are. So it’s about you know, communication. It’s about care coordination. It’s about respect. And when you look at patient experience in that way, you’re looking at helping patients and their families, reducing their suffering, or helping them reduce suffering and reducing anxiety. And in order to do that, what you have to do is you have to look across the entire continuum of care. It’s not just the doctors, it’s, it’s the front staff. It’s the nurses, it’s the techs. It’s the website, it’s, you know, the answering service. It’s all of those things. So patient experience is really about delivering truly patient centered care, and it’s about care that is, is also safe, and really high quality care. So again, not about making patients happy. I don’t expect patients to be walking out of my hospitals, out of my hospitals smiling and in tapping their toes and with a big thumbs up, but they are that’s great. But ultimately, what I think it’s about is it’s about making patients and their families feel cared for and feel respected and feel like their dignity has been honored. And so I think that’s what it is.
Unknown Speaker  5:52
So you want them to walk out, feeling like they’ve been heard. They’ve been understood. That they’re, they understand their care and that they’re making the right decision because your your outcome may not you might get the best care possible. And your outcome might not be great, but as long as they understand that’s a possibility, and that the person that was looking after them really had their best interest. And they got the best care by someone who
Unknown Speaker  6:25
absolutely, you know, some family members will walk out of the hospital without the patient that they brought in that patient may may die, and but you can still walk away from that experience and say, obviously, this is not an experience that makes me happy. But we had a good experience. Here we felt respected, we felt cared for. We felt our loved ones. decisions were respected. You know, we that kind of thing. I think, if patients can walk away feeling like that, then you’re on the right track.
Unknown Speaker  6:55
So I don’t think any physician would disagree with that. But I think The ways that we can accomplish that would be up for debate, right? So So what are some simple things you think that we could do to improve what we’re doing already. So as a physician, I certainly want my patients to feel like I care about them feel like I’m doing everything I can in their best interest and doing everything I can to make sure that they understand what’s going on. But clearly, there’s sometimes sometimes a disconnect between those two things. So now right now, I’m just talking about not the ancillary staff, not the rest of the experience, but just that doctor patient relationship. Do you have any tips for me, so that I can make sure that that they really feel like I care about them and their concerns, and make sure that they leave understanding what’s going on? Also, respectfully, in a time efficient? Sure, sure. And
Unknown Speaker  7:53
there are you know, it’s easy for me to say, these are the things that you have to do and doctors can very rightfully saved I have all of these other things I have to worry about. I’ve got a patient roster for the day, that is, you know, down to the ground, I’ve got so many patients I have to see in this time. But at the end of the day, if you’re not taking the time to make that, that one patient that, you know, is your most important patient at that time, right? If you’re not taking the time to make that person feel cared for then then what’s the point? So? So yeah, as we’ve been saying in this in this discussion already, you know, ultimately, what two patients want, they want the same thing that your kids want, that your significant other wants, that your co workers want, and they just they want to be heard. So there’s there’s no faking that that step or you have to be very good at it to fake it. There’s but there’s ultimately you have to make sure that your patients are heard, in terms of the kind of the quick and easy things that I think can go a long way making that happen. So here’s some suggestions. Number one, before you walk in to that room, take a deep breath. Just take a second, to let everything else go, you gotta let go of that patient list in front of you. Because right now the only patient that’s important is the one that you’re about to see. Let’s say, let that go, let whatever happened before, go make yourself centered to meet with that patient, come in, introduce yourself to the patient and introduce yourself to the family, the family is equally as important as the patient. Because just from like a practical standpoint, when they return those surveys, or they leave their comments, a lot of the time, it’s not the patients leaving those comments. It’s not it’s it’s the family member that’s doing that, you know, I’m in a role where I see complaints and concerns come in from from patients all the time and it’s their, their loved one or you know, their, their spouse, their daughter, their relatives, someone like that. So make sure you’re introducing yourself to patients and family who you are, what your name is. This is a pet peeve of mine, to be honest, when doctors come into a room and they’re seeing me or they’re seeing my kids They don’t say who they are. And they don’t they don’t know they don’t start with that. Make eye contact, make sure you’re making
Unknown Speaker  10:09
an excellent point, actually, is it? The position, I just assume that they know, they’re here to see me? Right? Who they make an appointment with? They made it to see Dr. Block at 1030. So when Dr. Block What’s when someone who looks male walks in at just because I assume they can see my beard on the picture when they make the appointment. They when I walk in at 1030, and they assume that I’m Dr. Block. Now, this certainly some of my female colleagues have have problems with that because there’s this, you know, they’ll they’ll sometimes be mistaken for nurses, which is right, clearly a problem. But yes, I assume that when I walk in the room, they know that I’m the doctor because your appointment with me. Right? I didn’t make the winner for them. But clearly you’re saying that that’s a mistake on my part. Something that I’m Yeah,
Unknown Speaker  11:00
I think so it’s just when you think about it, you know, some of your patients are booking with you directly, some of them might be coming in through to the referral. Right. So they’re there, they’re told you’re going to go see, Dr. Block is the same as Dr. Smith is the same as Dr. Jones in terms of in terms of all that, right. So there could be that there could have also been three or four people that came in to see them. Before him, my daughter just went to see an EMT and the nurse practitioner came in first. And it was a little confusing at first, when that nurse practitioner came in, I thought, Wait, is this the person I’m seeing? Are we going to be seeing somebody else? So so there’s there’s that as well. But the other thing to keep in mind is that often patients are in pain, and they’re scared. So their faculties are not going to be at the same level that you might expect them to always be, especially if you’re in an area of you know, like a really emergent area, right? You’re in the emergency room or something like that, you know, so I think it’s and also it’s it’s just nice manners, right? Like, it’s just nice manners to come in and introduce yourself to someone and now you’re creating the minute you do that the minute you look them in the eye and you say, Hi, I’m so and so and you may be confirm their name for them. Are you? Are you john? Are you you know, are you? You know, are you patient and you introduce yourself to other people. You’re saying, okay, we’re here, we’re present in this room together, we’re creating a relationship. We are starting our relationship right now. And even doing that can help put people who are in pain and frightened at ease. So introduce yourself to people make eye contact with them, right? Don’t be looking away. I mean, obviously, you got to look away and make your notes right in your computer, right your notebook obviously, but make eye contact. The other thing that I really like, is and I know this is this is not a new thought, but is to sit at eye level with them when you can, right try to if there’s a way to do it, where you can sit I level and not have your back to the family. You’re in great shape. right because the family is really there. They’re potentially A very large part of the care plan. So you want to involve them in that.
Unknown Speaker  13:03
Yeah, the electronic medical record definitely makes that sure. Challenging and we hear lots of complaints. So you know, it’s it’s a barrier between me and my patient. It’s, it’s one thing that I’ve found useful is is dictation software. So I use dragon. So I’m, I receive know to full disclaimer, I’m not being reimbursed, reimburse. But, but something that I’ve found useful is, rather than sitting there typing, although certainly I sometimes do if I have to make notes, if it’s a complicated story, but I’ll listen to the entire story. And then I will dictate back to them what I heard, so that that shows that I was listening, and they were understood, and this is what their story actually sounds like when said in chronological order, because generally, when people describe their experience, it comes out in the order of severity. At least this is what I’ve found in terms of severity, or urgency or importance, which says nothing for chronology which actually makes it more difficult for us to hear and understand. So then you repeat it back in chronological order. And then they know that that they’ve been heard and so that way you’re not looking at the screen. Yeah, you’re looking at them. And we all know from from medical school this is one of the things that I think was pretty universally taught when I was in medical school, which was that the patient thinks that you’ve spent more time with them if you’re sitting rather than standing. And so they always feel like you’re trying to leave if you’re standing so make sure to sit but you’re making the point even further. Try and make sure that you’re you’re on either level and if the computer isn’t is situated in such a way, you know, it’s really the onus is really on you to situate yourself so that you can you can interact with the patient whether that means using a laptop instead of the desktop or right there. There are ways to do it if you take absolutely and I love
Unknown Speaker  14:49
Brad what you just said about taking the time to kind of understand the story and recount it back to patients. This is actually something when I was at doc doc is something that we taught A lot of our reps who are on the phone speaking with, with customers, patients or doctors every day is you want to understand what the problem is. And the best way to do that is to paraphrase it, or even sometimes just plain old, repeat it back to them and say, Okay, so this is what I’ve got so far, or this is what I hear you’re saying, or, or just just to make sure I’ve got this straight and then you go back and you recount it. We have found in the customer service world that when you don’t take the time to do that step, the two pads of what the customer is telling you where the patient is telling you and what you think they’re telling you can can diverge really quickly. And you don’t you may not even ever figure that out in the span of the interaction, right? You make or if you’re lucky, you might find out the end. So some people feel this is silly. It’s like why am I going to the person said they were here for, you know, a sinus infection. I’m going to say, Okay, let me just get I just want to make sure I got the straight so you’re here for a sinus infection. Yes, that sounds a little bit silly. But take The time to make sure that you’re repeating back or finding a way to acknowledge that back to the patient says, okay, we’ve established this relationship, and we are on the same page.
Unknown Speaker  16:11
I think that’s hugely important. Also, because very commonly, there’s a question behind the question, right? There’s Yes, there’s the question that they’re asking. But then there’s, there’s something kind of underneath there maybe a bigger problem, maybe a more complicated one, that that they really, like, there’s subtext there, that they may not, and that putting that out there, really clarifies a lot in the visit. So if you can figure that out at the beginning, if it really does exist. If there really is a question behind the question, then that also makes it and then, like, it’s in our financial best interest, because and you’ve just saved yourself a ton of time. For the rest of the day. That’s right. by by by clarifying it and putting it out. That’s right. That’s right. And I think I think when you take the time to do that, and when you’re doing it with eye contact and you’re sitting with them at eye level, You’re kind of,
Unknown Speaker  17:02
you’re kind of getting away from that classic kind of paternalistic view of the doctor patient relationship, right? The one that that says you are the patient, and you’re down here, and I am the doctor, and I am up here. And I’m going to now Tell you what, you know, I’m going to tell you what to do. Some people are very comfortable, both doctors and patients are very comfortable with that relationship. The doctors that I like are the ones that can kind of, you know, meet me on my level, you know, connect with me, you know, connect with me as a person and take the time to look at me and repeat that story back. So now they now they understand where I’m coming from, and then they can get on to the deeper parts of the conversation. Like you said, What is the story behind the story? which then gets into deeper questions like what are your What are your goals for your health? What are your goals from this visit? What do you you know, if you’ve got obviously you’re here because, you know, unless it’s a basic checkup, you’re here because something is something is broken, something is not working the way you want it to work. So is this a simple Or is this going to be more complicated? It’s like, where do you Where do you want to be in, you know, a month, six months a year, depending on you know what they’re coming in for. And once you can, once you understand what their goals are, then I think the best thing you can do is you can present Okay, based on what your goals are. These are what your options are. And we can have a we can have a dialogue about what what you feel is the best for you and what I feel is the best for you. And now we’re now we’re really having a conversation, right? You’re still the authority, you’re still the doctor. But I feel like oh, my gosh, you really took the time to understand me, you asked me questions that maybe no doctor has asked me before. And I think all of that can happen when you’re when you’re really taking the time to establish that relationship. So taking that deep breath before you go in introducing yourself to patients and family. Continue to make eye contact all of them sitting at eye level, making sure you’re recounting their story back to them and getting to them about what their ultimate goals are.
Unknown Speaker  19:03
So I think this is what we’re describing right now is similar to that book How to Win Friends and Influence People, which is full of truisms. Right. Like people like hearing their own name. Like when you smile at them people like, right, like things that everybody knows, but most of us don’t do. So I think, how do we make that stuff happen? My suggestion, and I’d be interested in your feedback on this would actually be put a little sticky note, somewhere where you go, I mean, I have my laptop where I after I leave the patient room I like this is where I type this is where I return phone calls. And what I can what I’m going to set up after this interview is I’m just going to put a little sticky note on the counter. And it’s going to say, take a deep breath. Introduce yourself, you know, look them in the eye face them recount their story. Yeah. So that Between each appointment, I look at that and remember to do that. And that’s going to need to be there for a couple of months for sure, instill it until it starts to happen every time. And if you genuinely want to do these things each time, you then you need to develop them into a habit and develop them into the habit. You need to do them over and over and over and over. And I think it’s important to not just go Yeah, I’ll start doing that, to genuinely commit to changing your behavior, at least I need to, because I certainly don’t do all of these things right now. And if I’m going to improve my relationships with my patients that I need to do them, I’m going to do that so that I don’t forget, because otherwise, I’ll start running behind. I’ll get frustrated. I will forget and I’ll just go back to what I was doing before which obviates this entire conversation.
Unknown Speaker  20:51
So I certainly don’t want that absolutely. And you know, I say all these steps like you know, and you outline them on a post it note is that they are simple, but they’re not For some people, you know, not many people might say, you know, I didn’t get into medicine to create these, you know, cushy relationships with people, I came into my I got into medicine because I want to fix things that were broken, you know, but as I said before, you know, patients do have a choice as to who they’re going to see. And whether we like it or not, patients are saying that what is important to them is not just their clinical care, they, they, you know, they expect you to be clinically, you know, wise and put them on the right path. But the honest truth of the matter is, is that even if you’re wrong, if you have taken the time to really establish a relationship with your patient, they will often let that go. And that’s the same for a lot of different a lot of different areas. You know, if you’ve got someone that’s nice, you will forgive a lot of stuff, but there’s been studies that have shown that surgeons and primary care doctors are there sued less by patients That had really good bedside manner and really good communication really good rapport and respect for the patients like, they just they do it less they say,
Unknown Speaker  22:07
they’re less likely to sue someone that you like. That’s right. They say they say, it won’t make it completely go away, but it’ll decrease them. They say,
Unknown Speaker  22:15
you know what, I, I don’t care. I don’t care if he did this thing wrong. I love him. So we were talking about some of these potentially simple thing. But the The tricky thing, the hard one is the empathy component. And that is, I think that can be challenging for anybody to know. Empathy is not the same as sympathy, right? It’s really putting yourself in patient shoes, understanding where they’re coming from not judging them because patients are savvy and can tell when you’re judging them. But it is it is absolutely a muscle that requires time and effort. And I think it’s challenging for a number of reasons. One of them and I was talking to someone in our hospital about this recently. He brought this up and I thought was a really good point is that as doctors or healthcare professionals even we may not have have the best understanding of truly what the patient experiences? Because so you’re you’re affiliated with a hospital, right? Yes. Yeah. So if if God forbid, your children or your wife or someone or you know, gets a family member gets sick, and you take him to the emergency department of your hospital, chances are, you’re probably going to say to them, by the way, I’m Dr. Brad Block, I have privileges here, etc, etc. And why wouldn’t you like I would, at my own hospital, I would do that and I’m nobody at but I would go in and say, you know, I’m the patient experience coordinator here, blah, blah, blah. Because at that moment, I want to get the, you know, I want the best possible clinical outcome and I want to use anything in my arsenal to try and get me specialized care. I become very selfish in that scenario. But we’ll, we’ll use that if we have I feel like anybody in health care will use any trick that they can have at their disposal to try and get the best possible care. But you got to think about what it’s like for somebody who has no pull Who has no connections? Who doesn’t know that building? Who is you know, and also as the same things that we have, which is that they’re in pain and they’re frightened. So I think we have to really think about what is this? Like? What is this like for for this patient, even our, you know, even our patients who come in seeking narcotics CC, no drug drug seeking patients, obviously every facility has their share of them. But we still have to try and understand those people. And if we judge them, you know, they’ll they’ll come back and they’ll tell us they’ll say I was made to feel like I was like I was a drug seeker I would feel less than. And so empathy is really the trickiest of the things that I think we all need to work on. And if we can understand if we can work to understand where patients are coming from, the whole length of our relationship with them is going to be a lot stronger.
Unknown Speaker  24:49
Do you have any, anything that you could recommend for us that would help with that, but with where, where that might help me connect with my patients a bit better. Make them feel that Connecting with them?
Unknown Speaker  25:00
Well, you know, I think it’s kind of the things that we talked about before, you know, some of those steps. But I think it and this is something that we also you know taught at at Zach doc is that you know, you have to you have to, you can let people know that you understand where they’re coming from, you know, you can say, I’m sorry, that must be really frustrating for you. Something like that. I think even just acknowledging that because we can acknowledge, you know, all day long that someone has an specific injury specific malady, right, but taking the time to acknowledge what those feelings are behind it. Sort of sort of kind of like the story behind the story, like you said before, I think that can help is actually putting putting words to it, and letting patients know that you understand where they are, right. Like I said, this whole thing is about meeting them where they are understanding what their fears and their their goals are, but saying, you know, I understand that this is a lot of information I’m giving you and I can understand that will be that might be scary for you.
Unknown Speaker  26:00
So I think this actually leads into a common patient complaint, which is when we’re running behind, so I think we can we can, we can like meeting them where they are. So I think a lot of times when I’m running behind my impulse is to maybe explain why I’m running behind. Oh, there was a complicated patient, there was an emergency. A bunch of people showed up late, you know, something like that explaining, so that’s not meeting them where they are. That’s right. Having them meet me where
Unknown Speaker  26:36
they don’t care.
Unknown Speaker  26:38
Yeah, exactly. So
Unknown Speaker  26:42
so I think to that effect, meeting them where they are would be more just apologizing and saying, Listen, because they don’t want it. Nobody likes to feel like they’re not valued. Right. You spoke about that earlier. That’s right. Like they’re not cared about. So if I’m if I’ve just made someone Wait for an hour, that person feels like I have zero regard for their time and zero regard for anything about them. So how are they going to trust me to take care of them? If they think I, I just don’t care about their time at all? So I think in that situation, my inclination is to try to explain myself, but really what I should be doing from what you’re saying is, listen, I’m really sorry. I just want you to recognize that I do value your time and I feel terrible, terribly, that you’ve been made to wait this long. And I’m really I’m trying I’m, you know, I’m, I don’t even know if I should say that I’m trying to do my best or I’m trying to give up or just just apologize.
Unknown Speaker  27:45
You know, I saw something on on on Twitter of all places recently that said, What if we reframed it instead of apologizing, instead of saying, Sorry, I’m late. We said, Thank you for waiting for me. Right? We took the net. We took the negative I just thought about this, we took the we take the negativity out of it, we take the negativity of a word like sorry out of it. And we express gratitude for their patients. You know, and you don’t have to, I think you’re on the right track here. Like I don’t think you need to. You don’t need to fall on your sword about it. You can you can say, I understand your time is valuable. Thank you for waiting for me. I’m sorry, I’m late, even if you want to say that and say, and then what you do is everything you do from that moment on proves that they’re the most important person. You know, when when my first daughter was born, my wife’s ob gyn a really well known ob gyn in Manhattan. And this guy is notorious. His patients wait anywhere from an hour to like two and a half hours. And every every time we were in that waiting room, I sat there cursing him under my breath and like a complete, complete disguise. Wait, my time is valuable. I took off. When we got in the room, he made us feel like we were the only people that mattered In his world, and and this is a guy who had like celebrity patients on the walls, right, I felt we felt like one of these people, he spent a lot of time with us. He never made it feel like he had to get out the door and see the 20 other patients that have been waiting two hours. He spent as much time with us as we needed every single time. Every single time. I walked out apartment, I was like, I love that guy. Like, like, like, like it was totally, it was totally okay. And I want to I want to justify it to myself. I’m like, Well, I can see why we got to wait so long. It’s because he spends all this time with patients. That’s it. That’s a that’s an extreme scenario, right?
Unknown Speaker  29:37
Yeah, I don’t think we should be in annihilating that is something that
Unknown Speaker  29:42
I’m not saying.
Unknown Speaker  29:44
Here’s the thing, right? You don’t have to take all that time. You just have to make sure that the time that you are taking is really quality time.
Unknown Speaker  29:53
Well, you’re not distracted, right? You’re like you’re spending minimal time looking looking at your computer. You know minute. Yeah. And and you’re really and I think the to that effect the eye contact is is really important, right? Like, if you’re not distracted by other things, then you shouldn’t be distracted by other things. And it’s it’s sometimes, you know, maybe you’re trying to document as you’re talking to them. And sometimes there are ways to do that. Maybe I’m just trying to think of myself as the example. Maybe I shouldn’t be documenting things that they’re saying as they’re saying that, because then it seems like I’m playing Minesweeper when I should be when I’m, you know, just really just typing in what they’re saying. But But yeah, if you’re really absorbed in what they’re saying, then it makes them seem like they’re the most important thing in the room. And the most important thing in the world if you’re really, if you’re really that focused on them, and I think there are ways to do their ways to, to really practice that and I think that should end up on my little index card to, right. Just
Unknown Speaker  30:58
don’t be distracted. That’s Right. And if you’re concerned about what they’re going to think about you playing Minesweeper, that’s a simple one to you can say, so listen, the way I generally do things is I don’t want to miss anything. So I take a lot of notes, I type a lot. While I’m listening and you’ve got my full attention, I’m just typing at the same time, it becomes a distraction for you let me know, something like that. Now you’ve put it out there. Now they don’t have to worry. Is he playing Minesweeper? Is he typing an email? Like you’ve you’ve told them what what it is you’re doing and why you’re doing it? You know, obviously, I would suggest that any doctor, if they’re not in this space already is get comfortable with typing, but also looking at someone while you’re typing like I can, I can do that at this point. So I could look at somebody in the eye and completely just type in I can correct my typos later, you know, but just just let let patients know what you’re doing. Don’t assume that they know. And, you know, once it’s out there, then Okay, it’s fine.
Unknown Speaker  31:53
Great. Great, great. So, so far, I think we’ve gotten a lot of recommendations from you that are pretty high return on investment. So, you know, they don’t seem like a whole lot of effort, but they will really end up paying off in the long run, if we can turn them into into habits. Do you think there’s anything else that that you think that we could do that would be high return on investment? One thing that we had spoken about before the interview was how we treat our staff. So, you know, in in our offices, there is there are multiple levels before the patients get to us. They’re the people answering the phone, they’re the people greeting them and entering their information, then maybe you have a nurse or a medical assistant or physician assistant before they finally see the doctor. And so how can what are some high yield things that we can do to make sure that those people as well are maximizing the patient experience?
Unknown Speaker  32:56
Absolutely. Because like, like I said in the beginning, right, it’s about the entire continuum of Care and that involves that involves absolutely everybody. So this is where I see patient experience going in the future is, is all of these different areas, you know, from people from the doctors, to the nurses and housekeeping staff, the dietary staff, you’re in a hospital, finding ways that they can intersect and and meet patients where they are, right. So when it comes to, you know, nurses and you know, PCs, text, things like that, they, you know, they’re a big part of this as well, especially in the hospital setting, because in the hospital setting, they’re going to see the patients a lot more than the doctors, and quite honestly, you know, those other stuff they can, they can often make or break the experience. So I think what that requires, is that requires a connected team. That’s not necessarily easy to do. But I think it really pays off right? You have to have a you have to have a staff of people that feel like they’re all playing on the same team in a tool Gawande, his book, The Checklist Manifesto. He talks about how before surgeries, the entire care team would stand there. And they would, they would all introduce themselves and what their role was. And this felt awkward and silly for some people, but it ultimately made people feel like they were part of a team, even when some of them had never even worked together before. So what that requires is that requires people you know, the office staff and nurses and all medical assistants, all of those people to feel to be made to feel as if they are just as important in the patient care. It requires people to treat each other with respect, and dignity. You know, everyone in this way, I like to say everyone is basically a patient, right? Like you have to treat everybody that way. But if, if everybody feels like they’re playing for the same team, if nurses feel like they are being treated with the same amount of respect, you know, as doctors are, they feel like the doctors are treating them well. If the office staff feels that too, and everyone’s really working for the same team, and that team is the patient centered care team. That I think that goes a long way. But when they’re when there are when there are separations between those teams when people don’t feel like they’re as they’re, they’re important that their roles don’t have value in meaning. That’s when you see people I think start to check out. And the other thing that I’ll say and you know, is obviously, being in healthcare is really difficult. You know, you’ve got, you’re seeing people who are generally not at their, they’re not the best versions of themselves when they’re coming into the office, right? They, they may be there, they’re, like I said, they’re hurt, they’re frightened, they’re scared, they’re, they’re in pain. They’re, they’re probably not presenting their best versions, and they may take it out on you, and that is not easy to handle. And that can really burn people out. But the thing that stops them from getting burned out, is if you have a team around them that take care of each other, that creates engagement. So really, you need you need like team engagement there. I make that sound very simple. It’s not.
Unknown Speaker  35:57
Exactly so what I was going to ask is If there’s something concrete that you could recommend that we do in order to make these other staff members feel valued feel like part of the team feel like they’re on equal footing.
Unknown Speaker  36:15
Sure. Make eye contact says no, I mean I’m half joking but I am also serious like you know, when we’re talking about an office setting when you walk in in the morning, I’m not talking about you bread. I’m talking about the general you when you walk in the morning. Are you taking the time to say hello to the people you work with? Are you are you making I? I am talking? Yeah, I actually I’m talking about you. Are you are you? Are you making eye contact with them? Are you talking to them asking them how their day they’re doing? You know? As a quick aside here, when I was when I was working at doc Doc, at some point in my role there I started blocking off the first 15 minutes of my day and I know not everybody can do this. I would block up the first 15 minutes of my day to just talk to Everybody on my team just because I kind of wanted to see how they were. And when surveys came back about my performance, about like, what I should keep doing. That was like the unanimous number one thing that people said I should keep doing, I should keep coming in. So
Unknown Speaker  37:12
basically, they were like, I want to just keep talking about me. So here’s my feedback. In the morning, he asks me about me, I want more of that I want to keep talking about
Unknown Speaker  37:24
well, what they want is they want to feel like this is not just I am this person up here and you are this person. Again, it’s not the paternalistic relationship, right? It’s, it’s saying our relationship goes beyond just, you answer the phones and I treat the patients.
Unknown Speaker  37:40
So if, if I may make a suggestion I so what I would recommend and granted I have no expertise in this. I all my expertise is in ear nose and throat, doctoring and surgery, but would be for those staff members. You should know their names. You should know their spouses names, you should know their children’s names. And if they it, and if they have something like some of them are studying to be an ultrasound tech, some of them are studying to go to a PA school. Some of them are right if they have some aspiration, or some just know something, no, no, no their family members names so that you can ask them about them, and then know just something additional about themselves. So you can ask, so if you’re able to ask them that, then that shows that you genuinely care about them as a person, and their work will ultimately reflect that slowly, as far as like a concrete step that you can take. Should be that
Unknown Speaker  38:42
Sure, yeah. Because they’ll want to do a better job to for you, you know, they don’t want to let your your your your patients down. They you know, you’ve you’ve created a level of respect there. And I, you know, I hope people aren’t rolling their eyes at this thought of you know, of doing these things. And you know, what, if it doesn’t feel natural and Fake it a little bit, you know, and the more that you do it, the more natural it will become, people will at least see that you’re trying, which is, which is an important thing. But yeah, get to know those people. Even if it’s just like you said, even if it’s just a small thing or two that creates a relationship, all we’re trying to do here is create relationships.
Unknown Speaker  39:21
So as a little bit of an aside, I’m, I’m going to end the podcast just talking about myself. So the reason that I became interested in even having this podcast is, is that my wife, whenever I would go to some social event with her, she would just kind of float around the room, and then leave the party. And everyone felt like they had a new best friend in her. And she loves that type of setting where she can just interact with new people and she’s genuinely concerned about you know about about every, this is why she finds all them interesting. And yeah, this is why
Unknown Speaker  39:56
your wife and my wife get along so well.
Unknown Speaker  39:59
Exactly. But if, if, and you know me forever, for a very long time until only recently I was a curmudgeon, right? I didn’t want to interact with other people, I was angry, I listened to heavy metal, I had a frown on my face all the time. Like I was just an angry guy that didn’t want to interact with anybody. And I thought it was because I didn’t want to interact with anybody. But it was really because I was not good at it, which set up this negative reinforcement cycle of I’m not good at it. But really, I’m going to rationalize it that I don’t like it. And so then I just avoided it. And it just, you know, went downhill from there. But when I started learning more about it, and you know, observing my wife and reading, and as I got better at it, I enjoyed it more and then I got better at it and I enjoyed it more and I’m I’m certainly that translates into my patients experience as well because I try to apply those interactions skills to that interaction, and I think it’s helped me and the This is one of the main reasons that I’ve launched this podcast is I think that in medicine, we really have a lot to learn and myself included in that space, so it really, I really, I think we only scratched the surface. We’ve been at this for for over 40 minutes, and it feels like time just went by in a second. So I really just appreciate your taking the time out of your busy schedule to talk to me for this interview, I’d certainly love to have you back again where we can talk about other things,
Unknown Speaker  41:30
patient experience related, and thank you very much. Thanks so much for having the beds for the conversation.
Unknown Speaker  41:40
This was Dr. Bradley Block and the physicians guide to doctoring. Find all previous episodes on iTunes, Stitcher, wherever you get your podcasts and register review if you have something nice to say. You can also visit us on Facebook search positions guide to doctor
Transcribed by https://otter.ai

 

Common Misconceptions about the Patient Protection and Affordable Care Act

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Unknown Speaker  0:04
Welcome to the physicians guide to doctoring with me Dr. Bradley Block. Right interview experts and fields in and out of medicine to help physicians and other healthcare practitioners improve in all aspects of their practice to help them serve their patients, their practice their specialty, their community, their family, and most of all themselves. Better. Welcome to the physicians guide to doctoring Episode One common misconceptions about the Affordable Care Act. we’re interviewing Adam Block PhD, and health policy economics about the Affordable Care Act. We talked about the primary purpose and Origin The Affordable Care Act, and why did the cost of care go up after the Affordable Care Act? And did it actually have anything to do with the ACA? We talked about whether or not employers actually did drop coverage after it came out. And how did employee sponsored coverage which is the primary method in which people get healthcare coverage in the United States even come about why are some states turning down the Medicaid expansion, and why ending the individual mandate may not actually be the end of the Affordable Care Act. One thing that we do discuss very briefly are the 10 essential benefits. But I realized after listening to this interview that we never actually went into them. So I’ll just review them right now before our interview with Dr. Block. So the 10 essential benefits which are 10 benefits, which all insurances must have, in order to be considered health insurance and be able to sell their services are ambulatory patient services or outpatient services, emergency services, hospitalization, maternity and newborn care, mental health and substance abuse disorder services, prescription drugs, rehabilitative services, lab services, preventative and wellness services and chronic disease management as well as pediatric services including oral envision care. Now, prior to The Affordable Care Act. You didn’t necessarily have to have all of these. And one of the things that we discuss is how much this actually did change the cost of care after the Affordable Care Act came out. So without further ado, Dr. Adam Block positions guide to doctoring Episode One, interviewing Adam Block PhD. This is not a coincidence that we share the same last name, as we also share the same mother and father and father. So he’s my brother, but this does not make him an authority on anything, except possibly had locks and keys. But he happens to be an authority in the Affordable Care Act, which is what we’ll be speaking about today, what each physician should know about the Affordable Care Act given that it has become an integral part of everyone’s practice, it’s critical that physicians be as informed as possible without misinformation. So first Adam, aside from being my brother, what makes you an authority on the Affordable Care Act? So I’ll tell you a little bit about my background. Currently, I’m an assistant professor of Health Policy and Management in New York Medical College. They have a school of public health, a school Health Sciences and practices up in Westchester County, New York. But before that, I’ve done a few things. I received my PhD in health economics from Harvard in 2007. And pretty soon after that, I found that people were looking for health economist right at the start of the Affordable Care Act when right after Barack Obama got elected president on Capitol Hill, and I took a job I had a couple of job offers one with the Congressional Budget Office but took a job with the Joint Committee on Taxation, and I didn’t really think that tax had much to do with how healthcare, but
Unknown Speaker  4:00
I
Unknown Speaker  4:04
ended up ended up working there drafting legislation. And soon after that, after the formal Care Act passed, I went and worked for CMS where I wrote regulations on the Affordable Care Act. Great. So just give us a summary of the Affordable Care Act. It is an unbelievably complicated piece of legislature. Everyone talks about how many pages long it is, but see what you can do to just summarize it in five minutes or less. Sure. So it’s 25. So it’s 2500 pages long. I have read, I would say about half of them. I’ve contributed to the writing a decent portion of them, certainly not 1200 pages. But what the Affordable Care Act really does is it is legislation that is designed to expand coverage and that is it. That is its primary function. Is that Clint came around in 1992. And what they decided to do, and the primary reason that Clinton care failed, was that they tried to remake the whole healthcare system. They tried to put everybody in a CMOS are going to have these ATMs compete against each other, and they were going to change healthcare for everybody. However, the Affordable Care Act said, well, there’s a reason that this failed. And people were afraid of losing their health care coverage and the coverage that they have that they liked. And so when Obama got elected president, he said, Okay, here’s what we’re going to do, we’re going to do, we’re not going to change the employer sponsored market at all, we’re going to try to fill in the cracks because there are 15% of the overall populace that is without health insurance coverage. And so we’re going to try to cover them. And the way that they tried to cover them was with two primary expansions. One was a large expansion of Medicaid. And so if you live in a blue state, California, New York, the expansion of Medicaid was moderate. But if you live in a red state, and that red state has actually expanded Medicaid, the expansion was very, very large because many of those states did not have expansive Medicaid coverage. And the other thing that it did was it created exchanges, the exchanges or the individual market and it created some market rules around it. And it made healthcare coverage affordable for people like my barber barber makes $45,000 a year independent businessman does not want to go into Medicaid. But he has diabetes and would not be able to afford health care coverage if pre existing conditions were included. Because it would cost him 1500 dollars a month and that’s just impossible for someone that makes $45,000 a year. So for anyone who knows Adam knows that part of the reason is Barbara doesn’t make much is because he doesn’t visit him often enough. My hair looks amazing, especially relative to yours reason this is podcast. OK, so my barber would be able to get how is now able to help get health insurance. coverage through the Affordable Care Act. Because even though he was pre existing conditions, everybody is treated exactly the same. And even though even though he only makes $45,000 a year and coverage with my cost him five or $600 a year, he will get a five or $600 a month, sorry, he will get a coverage, he’ll get a tax credit of a couple of hundred dollars, maybe 100 or $200, to help him subsidize coverage. That’s pretty much it. That was really what the heart of the Affordable Care Act was. There was a third principle that they went in with, and this is important, maybe not from physicians perspective, but from a government perspective, which was that it was very important to Obama that it’d be budget neutral. And what that basically means is it that the Affordable Care Act would not add to the deficit. So therefore, if you have all of these additional expenditures, more people getting Paid for by Medicaid, that’s additional budget expenditure, more people going on getting tax credits, that’s an additional expenditure. Basically, you have to increase taxes or decrease spending elsewhere in order to pay for that. And I just want to contrast that with the tax cut the tax cut of 20 2017 act. And basically there was no that was a 1.512 $1.5 trillion expenditure where it was not covered. So it was important in the Affordable Care Act for it to be budget neutral. So budget neutral with regard to taxes. Some of the issue that physicians and patients both have with the Affordable Care Act is that the name ends up being rather ironic to many people because after the Affordable Care Act, the cost of their insurance went up considerably. And so
Unknown Speaker  8:57
part of that might be what we used to define insurance. Part of that is that with a pre existing condition, you can now join the insurance rolls. And that needs to get paid for somehow. Part of that is the 10 essential benefits. So I definitely want you to speak to that. And so so what are the some of the reasons that it may have been budget neutral to the taxes but not budget neutral to the, to the insured? Sure. So there are a few people. So for the vast majority of people, your insurance premiums did not go up, right? If you’re in employer sponsored coverage, there was nothing that changed about your coverage to make your premiums go up. Now, premiums go up every year, they go up. That’s why we have the right that that’s why we have medical expenditures that go up by four or 5% every year. So that’s not do just because that continued to happen under the Affordable Care Act is not mean it was as caused by the Affordable Care Act. So employer sponsored coverage did not really go up in terms of premiums. As a result of the Affordable Care Act. There were really no changes to it. There are there was a very small chunk of people for whom tax premiums went up for. And if you were in a in the individual market, and in a good risk pool, all of a sudden those risk pools all got merged together. And so the good preferred rate that you had may have gone away because you now had to cross subsidize sicker people than yourself. If you lived in a state like California, or another state that had a really broad range of premiums where young people paid way less than older people, that amount shrank, so your premiums might have gone up. So for those subsets of the population, and you were wealthy enough that you did not qualify for a tax credit, it’s possible that your premiums get went up. But for the rest of the world, premiums didn’t really change or certainly didn’t change as a result of the Affordable Care Act. Well, you hear stories about people that had insurance beforehand that may not have had the benefits that they have now because of the first Can we talk about the 10 essential benefits What what are they? Sure. So this is an area of my expertise, I wrote the regulation on the 10 essential benefits. And basically what it was is it was geared to be state by state and look very similar to what a small group or individual market plan at the time look like. So the 10 essential benefits were very similar to what was a standard plan being offered on the market at that time. So it was based on what was the standard of most plans at the time, this wasn’t a departure from what was typical for most plans. If you did not have these benefits, then you were the outlier. That’s exactly right. And and it was designed to prevent the outliers from getting way fewer benefits. An example of an essential benefit is maternity coverage. And I know that in Colorado maternity coverage was not mandated benefit. So you could buy a policy without maternity coverage. And so all of a sudden now you had to buy a policy with maternity coverage. But that does that most people are buying those policies anyway, the preponderance of coverage had that benefit attached to it. It just prevented you from basically opting out of that. So it didn’t allow some of the insurances to game the system and make it seem like they were giving a comparable product. Yeah. Whereas they weren’t. That’s That’s exactly right. And, and, you know, and what you’ll see is that the essential health benefits, which, you know, I’m very proud to have done work on, but I think it is a lot, Much Ado About Nothing. And the reason I say that is because the variation in benefits that have to be covered is really pretty narrow. You can identify a couple of points, but I just put out a Health Affairs blog post in January. And basically what that found was that the difference between the current state of the essential health benefits and Trump proposals that many people were crying the skys falling and they’re going to reduce our benefits to nothing. The total person reduction as a result of these proposals was about 1.2%. So if you’re losing 1.2% of premium, that means you’re only losing 1.2% of benefits that is not that much. So I think it’s 1.2%. It’s really much ado about nothing when it comes to the central health benefits. So what about the lifetime limit? Right, previously, healthcare was one of the most, if not the most common reason for someone to go bankrupt in the United States. Right. Do you know where that came from? Do you know that information came from where? So Professor Elizabeth Warren, now Senator Elizabeth Warren, built her career on bankruptcy law. And one of the big things that she found was that 50% of the bankruptcies were related to health care bankruptcies. So that was Professor Elizabeth Warren, that
Unknown Speaker  13:51
statistics. Now there’s this provision in the Affordable Care Act that says that you can’t have a lifetime lifetime limit on the amount that the insurance will pay. So if you end up for months in the intensive care unit, you have some exotic form of cancer and the treatment is exorbitantly expensive. You can’t run out of your limit on how much they will pay, they must continue to pay. The plan must continue to pay. Yeah, so who is really paying for that? anyway? So let’s, I mean, let’s take this. So you’re, you know, as a physician, let’s, let’s walk through how this would really happen. So first of all, if you had and, you know, a common cap, and I worked on this, the common cap was $250,000 on a on a plan. And when I say common, I mean of the crappiest plans that did this horrible thing. It was $250,000. It was not a common thing in the grand scheme of things. But let’s walk through what would happen now number one, and that’s what would you have to have to spend $250,000 on health care
Unknown Speaker  14:49
in how much time?
Unknown Speaker  14:51
Well, I mean, a lot of these were related to annual limits. I’ve heard lifetime limits, but not for plan lifetime limits for specific tools. A disease state. But let’s say let’s talk about it, you know, just just for as a thought experiment, let’s talk about it as as a year. So 200 What would you have to have to now what happens? $250,000? It absolutely happens. I’ve seen tons of data on this, but what would you have to have? I would think anything that lands you in the intensive care unit for a considerable period of time? Sure. So extremely severe trauma, maybe cancer, Nick, you any anything else that that might come to my come to mind. I’m an ear, nose and throat doctor. So there’s not much with us that that ends up unless the patients in palliative care. Most of the time if you have some uncle logic problem, you end up with a surgery in the surgical ICU and then hopefully from there, you’re improving. You’re out of the ICU and you’re always at your medical school graduation, something outside of ENT, I know it’s not going to be something related to NT. So, oncology, Nick, you maybe transplant Right. So yeah. So So those are a couple of the things. So let’s say you’ve got, right, let’s say you are have 100,000 $200,000
Unknown Speaker  16:11
transplants a great example.
Unknown Speaker  16:12
Yeah. Okay with that. So yeah, so let’s go with transplant. So you have a transplant a liver transplant, and it costs $300,000. Now, are you working? You’re not working? Right? So you don’t have commercial insurance. You stopped working and you somehow retained your individual market plan. Right. So your individual market plan says, I’m not paying anymore, you hit your cap. So then what happens? Well, you probably don’t have that much money. So maybe they drain your Well, maybe maybe they does the hospital kick you out? No, no, right. No, no hospital that you’ve worked in would kick you out if you know right now, and and i think that’s pretty standard. I don’t think hospitals kick you out, you know, in the United States. So as a result, there must be a law against that. You’d be surprised how recent some of these laws against that stuff happened. But yes, there’s there’s a lot against it. Plus, there’s the liability that they do something like that they end up in the newspapers, you end up with bad press, and nobody’s PR department wants anything to do with that. So either way, they keep you in the hospital, nobody’s kicking you out, right? At the same time. They’re not bankrolling you, right? So they, and they don’t want to be bankrolling you. So what do they do? Well, they try to drain your right. So maybe they’ll bill you until you run out of money. And maybe, but in reality, you’re probably going to get put on to Medicaid relatively quickly. And so the plan, so the hospital is then going to be building Medicaid. So the government is paying for it anyway, is the point. Right? But from the individual perspective, right, you’ve spent a considerable time working, accumulating savings, and then only to get a devastating illness and have a lifetime of savings wiped out. Sure. And so from a government perspective, from their entire budget, this one individuals problem, you know, whether they pay for it or not, but but to the individual, if you have To have your lifetime savings get wiped out in order to qualify for Medicaid and then to have it continue to be paid for that. Obviously devastating. Right. But I’m not saying that it’s a I’m not saying that’s a bad thing to have this provision in any way. I certainly don’t believe that. I think it’s a great thing to have. But what I’m saying is that the plans were basically jumped being a living off of the back of Medicaid. Yeah. So we were what you’re saying is that was whether we pay for it in terms of our individual plans having the lifetime limits, or we pay for it in terms of those patients, eventually getting on to Medicaid, and then Medicaid paying for the rest of it. We’re either paying for it in terms of our premiums, or paying for it in terms of our taxes, but either way, we’re paying for it. It just feels different when we’re paying for it in terms of our monthly premiums than if we pay for it in terms of this nebulous tax money that could be going to repair a road or could be paying for somebody Nikki stay
Unknown Speaker  18:59
Yes. That’s exactly right.
Unknown Speaker  19:00
So it just feels different. It’s kind of like giving someone $5 and then taking it back versus never giving them anything to begin with. It feels different, but it’s ultimately a zero sum game fest. It’s ultimately getting paid for by Medicaid, and in the vast majority of those cases where people hit upon the lifetime limit. Yeah. Okay. And so the amount that we’re talking about how much you have to drain from that individuals wealth, versus what the cost ultimately ends up being to Medicaid to begin with, is ends up not being that different just because of the cost of these days versus what people tend to have in their savings, right.
Unknown Speaker  19:39
The first time I’ve ever convince you of anything, yeah.
Unknown Speaker  19:44
Well, the rest of this is going to take a little more convincing. So. So there are I think part of what you do in some of your talks is you dispel misconceptions about the Affordable Care Act. So when you’re speaking to people about the Affordable Care Act,
Unknown Speaker  19:58
what are some of the more common mistakes perceptions about?
Unknown Speaker  20:00
Sure. So some of the more common misconceptions, the first is want to talk about death panels.
Unknown Speaker  20:07
And, yeah, that is that is a hot button issue.
Unknown Speaker  20:10
So I could tell you the true source of where death panels came from. So I think I know, I think I know the answer to this. And I think what it is, is incentivizing primary care physicians to have a conversation with the patients about end of life care. If you want to talk to your patient about end of life care, you’re not actually diagnosing a condition, you’re not actually treating a condition. So there’s no CPT code. So there’s no ICD nine code. So there’s no way as a primary care physician to get paid for this very difficult conversation. Is it? This is so phenomenal is that is that no that’s exactly right. That’s exactly right. Not as I don’t think it’s particularly smart guy you bend and well read and well informed might be from sitting at at the dinner table with someone who was involved in this I, I don’t I don’t want to give you too much credit. But But how far how far off the mark is that? That was 100%. Correct. And the only thing that I’ll add is that the person that sponsored the amendment was republican chuck grassley. So you know, it became political, it became a political football that people were saying, you know, there are these death panels in it, but nobody really knew what the death panels was. So it turns out with the death panels are his payment of a CPT code for an end of life care visit for, for primary care physicians as soon as you enter into Medicare, so very far from what a death panel actually is. So a couple of the myths versus facts. You know, first is, you know, on the democrat side, Obamacare is a panacea. It’s going to lower the cost of care for everybody. Not true. Not the goal was not targeted to be the goal and succeeded in not lowering the cost of care, meaning that Obamacare did not lower the cost of care. It was not meant to and it did not do that. Well, what Wasn’t there one part of it where there was a limit on the amount that health insurances could make? Like they couldn’t they couldn’t earn over a certain percent. And so if you cap their ability to make money and they have to give that back to their patients, then if they’re making less of a profit, then it costs less money. Isn’t that part of the affordable care? Yeah, so there was a cap on the medical loss ratio of 80% in the individual market and 85% in this small group market with the medical loss ratio is if you don’t find it too boring is the portion of the premium if you pay $1,000 a premium if you have an 80% medical loss ratio, what that means is that $800 if it has to go to doctors, and $200 of that thousand dollar premium, stays with the insurance company, let’s just be clear. 80% does not go to doctors 80% goes to care. That’s true. 80% goes to care. I think the and the breakdown that I see is something like about of that dollars, maybe $40 will go to hospitals, maybe 25 will go to doctors, maybe 15 will go to some combination of long term care, pharmaceuticals and medical devices. All right? Well, this is actually, we’ve talked about this before, this is going to be a different conversation that we have for another episode. So stay tuned, this is going to be the economics of health care in America. So that’s a good segue into a later talk. Okay. So did that actually did that provision, change things? Was that already the case in some states? Or did that actually lead to some savings for patients didn’t change things wasn’t the car wasn’t there in any states before this, to my knowledge, however, and the interesting thing is, and some of you may receive this is a check from your insurance company in the year 2014. When it when it first went into effect. People actually got checks back from their companies. Now, I don’t know anybody that’s gotten a check recently, and I actually just Article on this, why don’t people have checks anymore basically insurance either got a little better at pricing, or more likely they were able to cover up any sort of profits that they had that were in excess of this. Because in reality, what happened was they had some lines of business, some HMO, that we’re doing really well, that they might be right. And they had a year where nobody went to the doctor, there were no transplants. And they might be taking a huge profit in that year from that one. And others were they were doing really badly, right where they were losing money. And basically, that couldn’t happen anymore. So everybody, everyone they had to increase the premiums on everybody a little bit so that they would prevent themselves from giving the money back. So one of the other myths versus facts are.
Unknown Speaker  24:50
One concern that economists had is that Obamacare would cause employers to drop coverage and by dropping coverage. What that means is that all of a sudden, if there’s this big benefit, right? You get these tax credits to people earning families for earning less than $100,000 a year, they could potentially, employers could say, you know, what, why am I offering you coverage, if you can just get it in the exchanges, I’m going to drop coverage. And you’re going to be better off, I’ll give you a little bit of a raise, and you’ll get those big tax credits. This is what economists that worked for the Obama administration were terrified of. However, the data shows that there were the basically the same number, the same portion of the population that was employed, had employer sponsored coverage before the Affordable Care Act. And after the Affordable Care Act, there was really no change. So what economists were afraid of, which is that employers would just drop coverage and dump everybody into the exchanges and then the government would have to pay these tax credits. That didn’t happen. Was there a minimum number of employees that you had to have in order to be required, and then some people are some Companies ended up taking on more people as freelance and then not as full time employees didn’t have to pay for their health benefits. Wasn’t there some or there’s some complicating factors in there? I remember it being in the news. I don’t know the statistical significance of it. Because if you hear the story of something terrible happening, it tends to stick in your mind. But it might only be one person one time, but you know, what was the significance of maneuvers like that? So yeah, there’s an employer mandate, and the employer with the employer mandate says is that if you are an employer with 50 or more employees, that you have to offer coverage, and if you don’t offer coverage, you have to pay $2,000 fine for every one of your employees, for every one of your employees. Now, it’s a little more complicated than that. So I’m over generalizing it a little bit. But that was basically to make sure that employers didn’t drop coverage, but still, even if they had to pay that they might be better off because I know what you You know what your you pay in health insurance coverage for all of your employees. And I know what, you know, a standard premium rate for a family of four is here, it’s something like $12,000 and can range up as high to $20,000 in New York City. So $2,000, all of a sudden seems like a drop in the bucket compared to that they still may have made that same economic decision. But they did. The point is that they didn’t we have tons of economic evidence now that employers did not drop coverages or as a result of the Affordable Care Act. And there was a big concern that they would that this would fundamentally change what healthcare in America look like, from being an employer sponsored coverage country to being an individual market country, and they did not do that. But you said earlier that that was the goal of Clinton care. So that’s not necessarily a bad thing. Why were they so terrified of it? I think that that’s not what the objective of the Affordable Care Act was just because it was the goal of Clinton care. And now a lot of the same people that worked on Clinton care in their 30s then worked on the Affordable Care Act in there. 50s so a lot of these people were, you know, were the same people. But I think they learned from the experience and they wanted to make something that worked. And they recognize that people had a legitimate concern about moving into the about moving away from employer sponsored coverage. And there are a lot of benefits of being on employer sponsored coverage a ton. The most important is the tax benefit. Right? Anything that you pay in premium through your employer, basically is tax protected, you don’t pay tax on it. And whereas wages you do pay, and if you buy in the individual market, you do pay tax on it. So if I were to get, right if I’m in a 30% tax bracket, I get $100 in wages. If I buy health insurance through my employer, I get $100 worth of health insurance. If I take that in wages, I get $70 because I’m losing 30% and if I go by on the individual I have to get taxed on it. I get $70. And I go spend that $70 on individual market healthcare. And the reason that this was done is because otherwise it wouldn’t be budget neutral. No, no, it has always been like that. And nothing has changed that. And then why? It seems to me fundamentally unfair if when I pay for my own health insurance and my employees health insurance, that is paid by the business with pre tax dollars, but an individual Freelancer has to pay with post tax dollar tax dollars. That seems to me fundamentally unfair,
Unknown Speaker  29:34
and it is so
Unknown Speaker  29:36
yes, so that is, I would is going to segue into another question, which is one of the more controversial parts of the Affordable Care Act. This and it’s been, I think, discussed in this administration, the tax ability of of health insurance versus non taxable, so why why is that the case? So that’s historic. So what happened in World War too, was that there were not all the all of our boys went off to like our grandfather went off to fight and World War Two. And there were not enough. And not only that all of the factories in Europe had been bombed out. So there was no place to get guns or any sort of manufactured products. So the US was just turning it out and turning it on and turning it out. And so what did they do? They hired basically, the wage rate, right? If you’re an economics, well, the wage rate went up and up and up and up and up. And then the wage rate got so high that the federal government said nope, you can’t increase the wage rate anymore. So what employers do employers are savvy, they said, Okay, we’re going to offer some pretty sweet benefits on the side that are the equivalent of wages. And so that’s where health insurance really took off in the employer sponsored coverage. It didn’t really exist. An employer sponsored coverage didn’t really exist before the 40s and then and then the IRS in order to enhance it Basically passed a regulation that said that employer sponsored benefits like this would be tax deductible rather than a tax exempt. And if you look at it now, the biggest deductions in I’m getting to my tax committee experience. They’re two enormous what we call tax expenditures, basically giant deductions. One is mortgage interest, right? Everybody can deduct the interest that they take on their mortgage, which basically subsidized people to buy bigger houses and subsidizes housing prices. And the other is the exemption of health insurance expenditures. There’s the two biggest things. Now as a part of the Affordable Care Act, what they talked about was capping the tax expenditure on health insurance, saying, Okay, if you buy $10,000 without health insurance, that’s okay. But if you buy 15,000, you’re paying tax on the last 5000 of it. That was a big discussion. And the people that were opposed to that were the people that had high Premium states, like New York State. In fact, Chuck Schumer was the biggest opponent in the world of this along with john kerry, because they live in states where premiums are incredibly expensive. And so their guys, their constituents us would have had to be the ones that were paying tax on part of our healthcare. You mean for the employers? That I mean, the employers, but we were the individuals were always paying taxes on all of it. Sure. I mean, yes, yes, individuals are always paying taxes. But remember, individuals in the individual market only pay a very small, like, only make up a very small part of the very small part of the market, even today. I think it’s something like 25 billion, the 25 to 35 million people, it’s really not very much of the overall market. Right? So I think we’re, we’re running a little short on time. So just give me one more misconception about the Affordable Care Act something something exciting,
Unknown Speaker  32:59
something exciting.
Unknown Speaker  33:00
Okay, give you x LA for a little bit. All right, I’m going to give you my favorite one. So my favorite one is that members of Congress and their staff must be covered by the exchanges. So they made this special provision. And this this is a part of the fun political game that happens in Washington DC, where the Republicans who are opposed to the Affordable Care Act say if this, if these exchanges are so great, why don’t you get in them? So we’re going to propose that every member of congress and their staff needs to be in it. And normally would the democrats would do is oppose this they say, oh, everybody should be a Medicaid you should all be a Medicare, whatever it is, they say, you know, if it’s good enough for if you think this is such a good policy, then you should be in it. And instead what happened was the the majority leader basically said, Okay, we’ll be in it. I take your I call your bluff. And so now as a result and never change, and as a result, all the members of Congress that get health insurance through Congress are now a part of the DC exchange. I think it’s 11,000 people.
Unknown Speaker  34:07
What type of plans were they on prior to this?
Unknown Speaker  34:10
They were on FEHBP. So they were on the standard federal government plan, which is known for being a very generous, well subsidized plan. There’s tons of options. There’s maybe six or seven options in every region. So there might be a regional HMO, depending on where you live. There’s a Blue Cross Blue Shield option. It’s it’s a well known to be very generous. So we were talking about how individual plans are paid for with your taxed income and are not tax deductible. And that was something that could certainly use some improvement. Are there any other aspects? Having worked from the inside that you think either were lost due to maybe not enough political capital, or just some other aspects of it that could benefit from some improvement So, I mean, I think I think there’s a lot of complexity in there. The whole cost sharing reduction is cost reductions with the thing that Trump said we are no longer funding and, and, and legitimately stopped funding. And what these are his little bonus payments that you get if you are between, let’s say 200%, or 150% and 250% of the poverty level. Just to put that in perspective, 100% of the poverty level for a family of four is about $25,000. So these are families of four that are making something like 40 $50,000 a year and what that does is it reduces the cost reductions or roundabout way to reduce your deductibles and things like that. And that is a super roundabout way of doing something where they just should have said okay, if you want to give people in this tax bracket more money, just give them more money, give them better premium, don’t don’t make them is a two tiered system where you have multiple types of plans, it adds a whole lot of complexity in there. I also think they could have done a little more standardization of benefits. Because what we found is that there’s lots of behavioral economics research on this is that it’s really hard to make choices. It’s really hard to make choices. Plans are really complicated. And so if you standardize benefits, people have an easier time of understanding what, what they’re buying and making a better decision for themselves rather than just getting mired in complexity. So I think that’s a difference between maybe a libertarian and Democrat and Republican Some people think that if you have the complexity that people should be informed enough to make their own decisions. And at some point, these decisions that get too complicated for people to really be able to do enough research to understand the complexity of the decisions and at one point, it should just be made. Not completely for them but but just simplified. Yeah, I said certainly have patients that have signed up for the Block bronze plan, where they have low premiums and high deductibles. And then every time they go to the doctor, what they thought was a standard visit suddenly becomes a couple of hundred dollars. And and it’s not something that they were expecting. And so so I think Yeah, absolutely. I agree that that standardizing them somehow and making them simpler would benefit. A lot of people that that I’ve encountered in these situations, and this is where the they become disgruntled with the Affordable Care Act. And they say, again, the irony of the term, this isn’t this isn’t affordable. I don’t get any of my healthcare paid for until I meet this $5,000 deductible.
Unknown Speaker  37:44
How is this affordable?
Unknown Speaker  37:45
Yeah, well, they I mean, the irony of that is those people were uninsured before this. The right like that, that that’s the problem is that they want the world you know, like that a person that isn’t a bronze plan was mostly Likely uninsured prior to the Affordable Care Act. It’s not like they the as a result of the Affordable Care Act now they have a $5,000 deductible if they’re probably in a bronze plan, what was the situation that they were in, in 2013 likely they were uninsured and they were never getting coverage. And the reality, people should be budgeting for health care expenses that they are likely going to have, like, you know, potentially an EMT visit or primary care visits. It’s really the catastrophic coverage that you can’t possibly you can’t possibly budget for $100,000 that you get that you need to pay because you get cancer, right. Nobody can budget for that. And that’s what health insurance is for health insurance is less for the everyday visits. I don’t mean to diminish the fact that you know, it can cost you know, a couple hundred dollars to get a visit or to go to the to the ER this year 1500 dollars to the visit right now. I don’t mean to diminish that fact. That’s that’s real money, but those are real. Those are expenses that a reasonable person can expect to Have over the course of a year or five years, where as health insurance is really designed to reduce the catastrophic risk that you have, if you have a baby that happens to have to go to the NYCLU and you know, cost $500,000 or you have a heart attack, and you need, you need bypass surgery, and that’s going to cost $50,000. So then do you think the Affordable Care Act also has a bit of a PR problem? Because speaking of barbers, I went to a barber who complained that he went to the doctor and it cost him $200. And he has health insurance. So what’s the point of having health insurance if it cost him $200 out of his deductible, his eye then went into the details of actually exactly what you said, this is if he was thrilled if you have a catastrophe, this is going to cover that, but from his perspective also, because you can enter the roles now with a pre existing condition. He can just go without insurance until he gets sick, and so he doesn’t have as much of an incentive. He can’t, he can’t You can’t buy insurance in the middle of the year. So you can only buy insurance during open enrollment. And you basically have to be you can only buy insurance during open enrollment. So there’s ways to game the system a little bit, but he can’t game it like that. So then what happens to someone if they don’t have insurance, and they have some catastrophic event? catastrophic event? And it is just after the open roles closed? Now you have an entire year to wait before you can get insurance. Yeah, all those bad things that used to happen to you when you were uninsured before the Affordable Care Act. They still happening. Okay. Interesting. So they’re there. There are two things that were in the news, one more recently than the other that I want to get to.
Unknown Speaker  40:44
And, and one of them is
Unknown Speaker  40:47
that you had these conservative states that were offered the ability to expand their Medicaid rolls, right, they could get a bunch of their constituents on Medicaid with these Federal funds. Yeah. And they declined. Yeah. And he’s getting sued right now. I’m sorry. Main is getting sued right now, because they declined to put their well, because they the governor declined to put it on. Then they had a referendum vote in November of 2017. The referendum one, meaning they said that the referendum said that they had to expand Medicaid, and the governor did not has not done it yet, or is not intending to do it. I think it’s basically defining the referendum. So yes, this continues to be a big issue. Now, when the Affordable Care Act was written, none of this was conceived of at all, not even a little bit. The way that this happened was basically that when the Supreme Court case came around the Supreme Court case, and if I be versus rebellious of 2012, when Chief Justice Roberts who is a appointee of George W. Bush, right, a Republican appointee side of the four liberal justices, and said that the Affordable Care Act should stand and that is Shouldn’t be struck out of law. And that was because the individual mandate correct. So that was the individual mandate, two things came out of it. One is the individual mandate is constitutional. And two is that the state should not be compelled to expand Medicaid. So in the Affordable Care Act, what they said is, if you don’t expand Medicaid, we’re cutting off all of your federal funding for all of your Medicaid. And basically what the justices said was that no, you can’t do that the states have the option to do this, if they want to or not. And then all of a sudden, it became a political football instead of every state having to now it’s not exactly aligned with red and blue states. Because if you’re a hospital CEO, you know what, what do you want? You want all of you want all of the money? Yeah, you want all the Medicaid dollars that you can possibly get. So right now in the red states that have not expanded it, this hospital CEOs are saying the governor, please expand it. Because if I have, you know, if I have 20% uninsured or 15% uninsured, and I’m paying for that in my hospital with charity, care. And all of a sudden there’s something that can reduce that. And now Medicaid underpays the hospitals frequently. They don’t, you know, they pay them at cost or a little bit below costs. But it’s way better than getting nothing better than nothing understood. So why, aside from it just being a political incentive, right. This was this was the spent a lot of Obama’s political capital. Right. It was. They made it very controversial. They being both sides, really and
Unknown Speaker  43:34
you know, there was a lot of spin in both directions.
Unknown Speaker  43:37
I would argue that the spin was primarily on the on the right. And you know, and the evidence of that is pretty clear, which is that right, Governor Romney of Massachusetts, this is basically like, Governor Romney of Massachusetts is I you know, not his idea. He took it from, you know, american enterprise institute a republican Think Tank from like 20 years before. So this is this is these are you You know, right side ideas that, you know, because Obama came, and he, you know, he was Obama and the Democrats espouse them that they became offensive, but, you know, they were relatively, you know, right leaning ideas on how to expand coverage. Okay, I can appreciate that being left leaning myself, I wanted to try to stay as down the middle as I could. So but I understand that the, for the Republican governors to turn down what is essentially free money. Why would they do that? Was there something that they were going to be on the hook for later on, if they took this money over this basically turning down free money? It’s both. So they took that so they did turn down free money, but they would be on the hook for a portion of the Medicaid expansion payments. So from the year’s 2014 to 2017. The federal government was going to pay for 100% of the Medicaid expansion population, then starting in 2018. This year, the states were going to have to pay a portion of it, and then that amount was going to increase up until it was 10% of the of the amount of those those expenses going to cash it 10%. So ultimately 90% of expanding the Medicaid rolls would be paid for by the federal government, initially 100% eventually 90% but that’s it. It would end there. Yes, but that’s not being completely fed. So the answer is yes, that is absolutely true. But it’s not being completely fair. Because at the end of the day, the states don’t pay 100% of their Medicaid. They only pay New York pays 50%. And it varies state by state. The states with the lowest per capita income, maybe pay 25% of their state Medicaid. So the States did the federal government does not pay for 100% of Medicaid, the state it is a it is a mix of state and federal money. That goes into it. So in New York, it’s 5050. The Unexpected Medicaid. Yes, referring to standard standard Medicaid is a 5050 split in New York. And in some of the, like, Alabama, I think is 25% state money and 75% federal money. Okay. And the other issue that’s been in the news recently is with the new tax law, right with the new tax law, they got rid of the individual mandate they did. So that was a big coup. That was going to be the end of the Affordable Care Act,
Unknown Speaker  46:29
we say everything’s going to be the end of the Affordable Care Act.
Unknown Speaker  46:32
Right. And so just explain what that was. And then what has happened so far. So nothing’s happened so far, but know what what like so they got rid of the individual mandate. Explain that. Sure. So the individual mandate is a basically a tax law that says that if you do not have health insurance coverage, or you’re missing health insurance coverage for more than three months during the year that you have to pay a tax, and the amount of that tax is I believe, it’s $695 or the greater have $695 or 2.5% of your income. Now, if you make $100,000 2.5% of your income is 20 $500 a year, right? That’s the amount of the individual mandate rip. That is actually still in effect, it was in effect 20 1415 1617 and is still in effect for 2018. But is not in effect for 2019. And the purpose of it was to prove to keep young healthy people in the population to give them a stick to hit them with a stick to say you better be in otherwise we’re going to tax you. And so the question is what’s going to happen to the risk pools what’s going to happen to premiums for the people that stay in, because the guests of actuaries and economists is if you’re young and healthy, you’re 22 years old, and you’re facing a decision of I could pay $400 a month for premiums, or I could not pay $400 a month from framers and roll the dice. Most of them are going to win that dice roll and so they’re not many of them are not going to pick $400 a month for premiums. Now, if you add attack on, oh, if you don’t pay $400 a month for premiums, I’m going to get a tax. And you know what you get for that tax, you get nothing, you get nothing for that tax, right? Do you pay the tax, you don’t get health insurance, then a lot, it’s going to push a lot of people into the insurance market. Now the question is whether people are going to flock out of the of the insurance market, whether you’re going to flock out of the exchanges as a result of the Affordable Care Act, no longer requiring you to have coverage. Now, I don’t think it will. Congressional Budget Office would disagree with me. They think there’s going to be 4 million people, fewer people insured next year, all the way up to 10 or 12 million people 10 years out. So what was the tax for those people? Right now? Right, those people that are going to fall off the rules, potentially they’d pay 2.5% of their income right now. They’re up to $25. Right now. They’re at two Point 5% Yeah, okay, so escalated to that point. And that was it. Yeah. First year, it was like 1%, I went to 2%, then I went to 2.5% of their of their income. Okay, so the question is whether these people were just not going to buy insurance. Anyway, you know how many of those people just never bought insurance to begin with, and we’re just paying the tax, maybe not even realizing that it was going to happen to them, maybe not even realizing that that was something that they needed to do. And what percent of people are just people who want to have health insurance, because they want to do the responsible thing. And then there’s all those people in between that are going to make the informed, calculated decision. And I tend to think that there are not that many people that are going to sit there and calculate how much it costs, the risk, the benefits, they’re just going to be the type of person to buy health insurance, or they’re not going to be the person the type of person and it depends in large part and how much their mother yells at them, to be honest. You hear that tons is like, Oh, my mom reminded me that I have to go buy health insurance, right? Because a lot of these people are 20 to 30. You know, the in the 20 to 30 group, and more and more of them are living at home for longer periods of time. Yeah. Although, you know, one thing that the Affordable Care Act did the single most popular provision of the Affordable Care Act was the expansion of coverage till you’re that you can stand your parents planet to 26. Yeah, cost the plans. Very little. Parents are happy because we’re happy. It was like a win win for everybody. Well, wonderful. Is there. Maybe one more point that you want to add before we wrap this up something that we didn’t cover that you think it’s important for people to know or a common thing that people misunderstand?
Unknown Speaker  50:37
Yeah. Mom and Dad love me more.
Unknown Speaker  50:41
It’s, it’s true.
Unknown Speaker  50:44
I’m hoping this podcast wins the moment.
Unknown Speaker  50:49
Well, thanks a lot for coming and taking the time to talk to me.
Unknown Speaker  50:53
He is going to be back on the show because I know where he lives. And if you do have questions, please post any comments on the Facebook page so that the next time he is available, we can circle back and clarify anything, either regarding the Affordable Care Act or
Unknown Speaker  51:11
health economics in general.
Unknown Speaker  51:13
Well, Adam, this has been very informative. Thanks a lot for your
Unknown Speaker  51:15
time. It’s been a pleasure.
Unknown Speaker  51:18
This was Dr. Bradley Block at the physicians guide to doctoring. Find all previous episodes on iTunes, Stitcher or wherever you get your podcasts and register review if you have something nice to say. You can also visit us on Facebook. Search for physicians guide to doctor
Transcribed by https://otter.ai

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Unknown Speaker  0:04
Welcome to the physicians guide to doctoring Episode Three, what every doctor should know about gi issues. We’re interview Dr. Daniel Marino, gastroenterologist at the University of Rochester and currently the fellowship director about things that every doctor should know about gastroenterology. And when I say every doctor, I mean, like myself and otolaryngologist, a pathologist, radiation oncologist, what are gi issues that every doctor should be familiar with? We talk about the fun stuff. Diarrhea, went to be worried about it wouldn’t be less worried about it.
Unknown Speaker  0:44
GIP
Unknown Speaker  0:46
when is that potentially a catastrophe. And when can you wait a couple days before really starting to worry. What’s up with gluten? We get an interesting take on gluten from the gastro Just add some fun cocktail party facts about the GI tract. It was a fun conversation. I enjoyed it, and I know you will. Welcome to Episode Three of the physicians guide to doctoring. This episode is about gastroenterology. We have one of my
Unknown Speaker  1:22
good friends from medical school Danielle Marina. Danielle, thank you for being with us today.
Unknown Speaker  1:27
Thank you for having me bread.
Unknown Speaker  1:29
So Danielle and I were at SUNY Buffalo together. And then after we graduated, where do you go?
Unknown Speaker  1:37
I did my internal medicine residency at Yale in New Haven, Connecticut. And then I started fellowship at the University of Rochester. And I stayed on there as faculty. So right now I’m an assistant professor of medicine there, and I’m the GI Fellowship Program Director.
Unknown Speaker  1:55
Fantastic. Look at what you’ve done with yourself. So That definitely gives you a lot of street cred when talking about all things gastroenterology. And so today’s show, we’re just going to be talking about everyday facts that the general population should know about gi. But more specifically, doctors should know because, you know, we’ve all had situations where one of our neighbors asks us for advice, and you might be a pathologist, and you don’t know anything about gastroenterology except for one or two clinical rotations that occurred five or 20 years ago. And so, you know, you’re expected to know things because you’re a doctor, but they may be completely outside of your specialty. So, so today, Danielle, I want to talk to you about some things that that that both of us think that just the every doctor should be somewhat familiar with. As a disclaimer, Danielle is employed by the University of Rochester and I’m a partner at NT and allergies. So associates, both of us are currently representing ourselves and other organizations. And so anything that you hear does not represent the views of those organizations, but are solely of our ourselves. That being said, we’re also going to be talking about some clinical information and we can bear no responsibility for outcomes that occur based on advice that you take here. So as the radiologist like to say, clinical correlations are recommended. So, so Danielle, let’s start off talking about one of my favorite
Unknown Speaker  3:38
activities against one of my favorite pathologies, diarrhea.
Unknown Speaker  3:45
All right. So this this should be a fun one. So So one thing is, let’s say the scenario that I have before my my neighbor is mowing his lawn and has to keep running inside Because he has very bad diarrhea. So he sees me blowing my lawn and says, Wait a second. You’re a doctor. Let me tell you about my diarrhea. Mm hmm. Yeah.
Unknown Speaker  4:14
Yeah, that happens to me regularly.
Unknown Speaker  4:17
I would imagine, but hopefully those of your patients and not your neighbors,
Unknown Speaker  4:21
sometimes the mail lady, okay.
Unknown Speaker  4:24
Okay. I guess she sees those offers for a job in the Midwest by Lake an hour and a half. Exactly. And she knows that you’re being offered gastroenterology, so she kind of figured it out and can now ask you, she’s carte blanche to ask you for advice. And you have to give it to her otherwise you’ll get your mail. So, okay, so diarrhea. So, so I want to break this down into to two things. Really, when is it time to worry? What are we looking Four. So what are the important questions that we want to ask said, neighbor? And what are the potential catastrophes? But what are the horses? Right? What are the things that that it probably is? So first, what are the red flag questions that you’re going to ask to make sure that it’s not some potential catastrophe?
Unknown Speaker  5:18
And say the main thing is like, is there blood in the diary? So if it’s bloody diarrhea, it’s probably something serious, it could be an infection. But if it lasts for more than a week or so then it’s probably something more than just an infection. So, if there’s blood in it is probably the first question I would ask. If there is, you know, I’m thinking something like inflammatory bowel disease like ulcerative colitis or Crohn’s disease, maybe even something like colon cancer. So, those are bad. Then you want to ask like, Are you having nocturnal diarrhea, so usually, you know it’s normal that people have bowel movements, usually first thing in the morning or after eating. And that’s because we have something called the gastro colic reflex when your stomach descends with food, it leads to parasitosis of the colon and you dedicate and but if you have some sort of pathology going on that may have you have diarrhea even at night. So usually if it’s at night, that’s something organic going on, again, like inflammatory bowel disease. Things like irritable bowel syndrome, which is super common and probably the most likely thing causing diarrhea and most people, people wouldn’t be waking up in the middle of the night have bowel movements. So nocturnal diarrhea is definitely a red flag. blood in the stool and then I’d say you know if it’s going on for a long time, and it’s not a beating. If there’s any weight loss or signs or symptoms of dehydration, like lightheadedness, dizziness, palpitations, Or any other kind of symptoms that go along with it like vomiting or severe abdominal pain, those are all kind of things that mean that your neighbor should probably go see a doctor and not just talk to you while he’s smelling.
Unknown Speaker  7:14
So, so what but what can we use to differentiate an ER visit from an hour waiting for an outpatient appointment? So clearly dehydration, if you’re showing signs of dehydration, you can’t make an appointment for doctor that may occur in a couple of weeks. Right clearly, that’s that’s an emergent issue. So if there’s, if there is, are there signs of dehydration, go to the ER, if there’s blood in the stool. So we have we’ve talked about this before just to take a little aside.
Unknown Speaker  7:47
Should they have a Hema called test?
Unknown Speaker  7:51
Oh, Jesus, no. So a Hema cult test is called that for a reason. It’s looking for a cult blood, meaning blood You can see. So I mean, if it’s frankly bloody, you don’t need to do a Himachal, we know that it’s bloody. So if someone’s complaining of bloody stool, that doesn’t necessarily mean they need to go to the emergency room. I mean, it kind of depends on the situation if it’s a copious amount of blood or if it’s just rectal bleeding without diarrhea, per se, yeah, that’s probably warranting an emergency room visit. But if it’s a little bit of blood mixed in with your diarrhea and it’s been going on a bit, see a doctor as long as you don’t have you know, signs and symptoms of significant anemia or dehydration, you don’t have to go to the emergency room.
Unknown Speaker  8:37
So anemia dehydration, which can have similar symptoms, those would be reasons to go to the ER otherwise, you know, just get to your at least your internist if not a GI doctor pretty pretty quickly. Okay. Fantastic. So you also mentioned GI gi pain, with with the diarrhea, let’s say the let’s say he’s mon as long And he’s he’s, he’s a little slow because he’s got a stomach ache. So he doesn’t have diarrhea, doesn’t have nausea, vomiting. It’s just stomach pain. So, you know, acute stomach pain, chronic stomach pain. Well, let’s let’s talk about acute, really, first. When when is this an ER visit versus an outpatient visit?
Unknown Speaker  9:25
I’d say, you know, there’s a million things that can cause acute abdominal pain, but I think if it’s someone that doesn’t normally have abdominal pain, and they have severe abdominal pain, there’s a lot of serious things that could be happening. So if this is a person that has no gi symptoms normally and all of a sudden has severe abdominal pain, no matter where it is, they really should go to the emergency room. It could be something serious like coli cystitis or colon Titus, diverticulitis, and abdominal perforation from for some reason, you know, perforated peptic ulcer or perforated colon, mesospheric ischemia. So there’s a lot of like serious things that could turn into like a surgical emergency if ignored with acute onset of severe pain. That being said, you know, there are a lot of people that have actually like chronic abdominal discomfort and people who have irritable bowel or some what we call like functional abdominal pain, which is more of like a nerve related issue. And those people who have kind of chronic abdominal pain may have acute bouts of and they don’t necessarily mean to go to the emergency room every time I think, you know, we need to take it in context of what the baseline is and things like that and where the pain is and if it’s related to deprecation and such.
Unknown Speaker  10:48
So clinical correlation recommended
Unknown Speaker  10:50
absolutely, always.
Unknown Speaker  10:53
Disclaimer, right. So he’s saying, This is the worst stomach pain of his life, he should probably go to the ER But if he says, but it’s pretty similar to the stomach pain I had yesterday and the day before and the last few weeks in the last few months, that speaks to the lack of lack of urgency, because there seems to be.
Unknown Speaker  11:10
Yeah, and we’ve all seen the patients who claim they have 10 out of 10 or 12, out of 10 pain as their, you know, on Facebook role. So, like, you know, you kind of have to take it with a grain of salt and see what, you know, if they’ve had it before, and things like that. But
Unknown Speaker  11:27
I actually have a personal aside about my own gi pain, because I have you on the phone. So free comes to take advantage of the opportunity. Yeah, Indeed, indeed. It’s actually it’s not a concept. It’s just I think it’s an interesting story. So my wife and I were on our honeymoon, which was a safari in Tanzania. So we were on the flight back. And it was it was amazing as we were on the flight back and I started to get some stomach pain. And it was pretty bad, pretty bad. And it would happen After I got back every time I ate, and I was just I just stopped eating because it was so severe. And I thought it was constipation. So I just tried treating myself with some over the counter stuff and you know, nothing was working. And ultimately, I saw gi I hadn’t Ed, everything was fine. Here’s what it was. She was pregnant with our first child. And this is apparently a phenomenon. This is not unheard of for for like anxiety and I’m sure you see this anxiety related abdominal pain, and it had nothing to do with a trip to Africa, or having eaten something I didn’t have God. It was just because I was anxious because he was pregnant with our first kid. So
Unknown Speaker  12:49
So I as I like to say the GI tract is the window to the soul. So whatever
Unknown Speaker  12:58
feeling on the inside, usually presented itself with, you know, some gi distress, or, you know, they say butterflies in the stomach, you know, all those things are related to kind of what’s going on in your life. Stress definitely affects the GI tract significantly. And that’s because there’s almost as much nerves in the GI tract as there are in the spinal cord.
Unknown Speaker  13:21
And really, Mm hmm.
Unknown Speaker  13:24
There’s like a ton of nerves and neurotransmitters and it’s really complicated between the brain and the gut connection, but definitely they both interact with each other. So stress can cause gi symptoms and gi symptoms can cause severe stress or anxiety or depression or, you know, other neurological symptoms. So it’s pretty interesting. Yeah, and it’s hard to sometimes it’s hard to tease out, you know, what’s an organic, you know, structural problem versus more of a nerve related issue.
Unknown Speaker  13:57
Yeah, that’s probably one of the things that’s more challenging. For you to figure out when you’re doing your outpatient console, isn’t it?
Unknown Speaker  14:04
Absolutely. Definitely, history is like huge. It’s all about taking a really good history. And sometimes, you know, patients aren’t really able to give you a good history. So sometimes it’s difficult. You have to do you know, some tests that maybe you didn’t necessarily want to do, but you have to roll something out.
Unknown Speaker  14:22
Sounds like that is the post nasal drip of otolaryngology,
Unknown Speaker  14:26
I can imagine, or LPR
Unknown Speaker  14:29
or or LPA. Well, that’s the those two things are intertwined. This like mucus sensation in your throat when they have normal nasal exam and laryngeal exam and everything and all this throat clearing and that can be very, very challenging to figure out. So I guess we all have our own. Every specialty has their own post nasal drip. Yep. So that was interesting what you said about the number of nerve endings in the GI tract. So it was Something else that we wanted to talk about? What are some other cocktail party facts that you might be able to share with our listeners? is there is there anything else that you even if you might find it interesting for you, and you might think it’s boring to us. I doubt that I think I’m gonna find it interesting.
Unknown Speaker  15:20
Well, um, okay, one thing that people don’t realize is that like, there’s no set definition of like diarrhea or constipation. So like, it really just depends on the patient. And the variation of normal is pretty big. So we consider normal anything from like, one bowel movement every three days to up to about three bowel movements today.
Unknown Speaker  15:46
The rule of threes, the poop, the poop rule of threes,
Unknown Speaker  15:50
so race, so every area
Unknown Speaker  15:53
or every three days, all normal,
Unknown Speaker  15:57
but even I mean, that’s kind of wishy washy. Because if someone tells me Well, you know, my whole life I’ve had four bowel movements today and that’s just been me my whole entire life then that’s probably normal for them. And I’m not overly worried about it, especially if it’s not bothersome to them.
Unknown Speaker  16:14
I think it’d be hard to hold down many jobs with
Unknown Speaker  16:22
Yeah, that’s gonna, my patients would get pretty upset. really willing again, cuz he’s, again,
Unknown Speaker  16:30
really well that’s, that’s something that I find interesting. You know, some people take about 30 seconds to have a bowel movement. And for some reason, it seems many men take like three hours. I kind of think you use it as an excuse to like hide away in the bathroom with your phone and like, fall down a rabbit hole in the internet or something shouldn’t have to take that long.
Unknown Speaker  16:56
Listen, those those patients then end up getting hemorrhoids. True keep keep colorectal surgeons in business.
Unknown Speaker  17:05
Oh, here’s a fun fact.
Unknown Speaker  17:08
So you don’t have that may or may not include me.
Unknown Speaker  17:12
So you know how we sit in this country we sit on a toilet to go to the bathroom. I know, Brad, you’ve done a lot of traveling. And you see like in other countries, people don’t necessarily sit on the toilet like they’ll swap
Unknown Speaker  17:25
down toilets. Yep,
Unknown Speaker  17:26
yep. And so that’s actually the best way to dedicate because it opens up the anal rectal angle. There’s a muscle that kind of as a sling muscle and pulls on like the rectum. It’s called the pubic talus. And when you when you squat down, that actually opens up the pubic talus muscle and opens up that angle so the poop can come out easier.
Unknown Speaker  17:49
I would also imagine that you’re because you’re folded up like an accordion. You’re also squeezing things a lot more.
Unknown Speaker  17:56
Yep. And it helps your abdominal muscles, musculature, you know work better than if you’re Kind of stretched out. And
Unknown Speaker  18:03
this is why have you seen the Squaddie party?
Unknown Speaker  18:06
Yes, but the like the weird unicorn
Unknown Speaker  18:09
rainbow ice cream? Yeah.
Unknown Speaker  18:12
We didn’t do any disclaimers at the beginning. are you receiving any compensation from the squad?
Unknown Speaker  18:16
I have no financial
Unknown Speaker  18:18
disclosure. So I’ve made financial disclosure.
Unknown Speaker  18:21
I am a big fan of the squatting money because that is the correct way to put their right. So I do recommend that to my patients a lot and it avoids straining and kind of prevents you from developing Hemorrhoids and it makes a really good Christmas present. I have given it to many people
Unknown Speaker  18:38
really.
Unknown Speaker  18:40
That’s funny because we give for for newborns we always give the snot sucker. Oh God,
Unknown Speaker  18:45
that thing freaks me out.
Unknown Speaker  18:50
Like gifts that are related to what we do. specialties.
Unknown Speaker  18:54
Yeah, well, we realized we find it useful. OK, so the Squaddie party seems a good alternative to standing on your toilet seat and then squatting down.
Unknown Speaker  19:06
I have had a pinch tell me that they do that though. Like, just casually mentioned. Oh yeah, my whole life I just put my feet on the toilet seat. Now was
Unknown Speaker  19:13
that person born in a country where that is a routine? Oh, no. It was a good idea.
Unknown Speaker  19:20
She actually I think she she has a definite contrary disorder. She has a problem where her you know sphincter doesn’t relax and she kind of figured it out realized that without knowing exactly what it was and kind of worked around it on her own and never talked to any doctors about it.
Unknown Speaker  19:34
So some people self treat things like anxiety with marijuana and she self treats her erectile dysfunction by squatting. Yeah, well that’s that’s I have to say that is pretty impressive. That she was figure that out and had just been doing it her whole life.
Unknown Speaker  19:54
And when and when the patient told us that like when I went back in the room with the fellow the fellow is Pretty like shocked that the patient made her own diagnosis. Yeah, that’s like okay, we know what the problem is. Thanks.
Unknown Speaker  20:09
So, fun facts one
Unknown Speaker  20:11
fact. So I have a question. Just things that can turn your poop. Different colors, not not pathologies, right? Like remember there’s something that causes khaki colored poop, right?
Unknown Speaker  20:22
Oh, yeah. Well like clay clay colored. Yeah, that’s when you have like a billionaire obstruction. gonna lose the Bible because the Bible is what makes your poop brown makes it because if you lose your Bible, you can have like a white. Sorry.
Unknown Speaker  20:46
biliary obstruction.
Unknown Speaker  20:49
She knows now, biliary obstruction.
Unknown Speaker  20:55
What about stuff that you can
Unknown Speaker  20:59
that you can eat that We’ll turn your different colors.
Unknown Speaker  21:03
So beats concerned your poop red. Okay? I do not like beets thankfully but beats continue to poop red pepto abysmal concern or poop black and a lot of I can’t tell you how many times like we’ve been consulted for melanoma, which is you know black stool it’s supposed to mean an upper gi bleed. But really it just turned out the patient was eating a bunch of pepto abysmal and so that’s why it was black iron pills can also turn your stool black.
Unknown Speaker  21:32
Well, hence the need for a humid cold right because then because that’s not Frank. That’s like water not like what about the patient right? Like, then you’re doing a Hema Colton someone because you can’t tell if it’s blood or beats.
Unknown Speaker  21:46
So you can kind of tell the difference, actually, yeah, it’s red, but it’s like, it’s like a weird red. It’s not like a blood. Right?
Unknown Speaker  21:53
That’s, that’s what I tell my patients about tonsillectomy. So one of the things that you read on the internet after tonsillectomies, don’t drink anything, Read because you won’t be able to tell the difference. If you’re if you’re bleeding, which is a common problem after tonsillectomy, you won’t be able to tell your if you’re bleeding or if it’s Hawaiian Punch. And so what I tell my patients is one of the risks is dehydration. So if all you can get your kid to drink is red Gatorade or Slurpee or Hawaiian Punch, like we can tell the difference between Hawaiian Punch and just get them keep them hydrated. Absolutely. Those those misconceptions start.
Unknown Speaker  22:29
Yeah, so have you ever smelled melanoma? I’m sure you. I mean, people know like, you can tell the difference between that at this point.
Unknown Speaker  22:38
I’ve been doing total laryngology for, you know, four years in residency and seven years and so 11 years. So if I’ve smelled Melanie, it was over 11 years ago, but I you know, I can still remember it.
Unknown Speaker  22:51
It’s one of those things. Yeah, don’t forget. Yeah,
Unknown Speaker  22:53
it’s one of those things. I remember hearing in a lecture in medical school. Yeah, their poop really smells bad. Everybody’s poop. Oh, wow. Yeah, Melanie, okay. Yeah, no, that is a whole different level. So you don’t really need to just remember cold because oh my god that is room clearing. Yeah.
Unknown Speaker  23:11
Right? And Hema cold. So Hema calls is actually made for colorectal cancer screening, there’s really no indication to use it otherwise, it’s not to look to see if someone’s bleeding because it can have a lot of false positives, you know, someone has Hemorrhoids and they can have a
Unknown Speaker  23:28
positive from sitting on the toilet for three hours at a time absolutely going down or you know, rabbit hole,
Unknown Speaker  23:36
and especially getting like a rectal exam and then doing the chemicals. That’s like a huge show. Now, even just putting your finger in can cause some minor, you know, trauma that can cause the chemical to be positive. So if someone’s gi bleeding, like will know, like, you know, you check the credits. Blood is a laxative. So if they’re actually gi bleeding, they’re going to be going frequently. They’re not going to Just have like one bowel movement a day or whatever their normal. So like builds a clear themselves. We don’t need the chemicals, it’s not going to help us. Stop doing him and GM and chemical positive is not a color. So we always ask what colors is still and they’ll say positive. I’ve never seen that on a crayon.
Unknown Speaker  24:20
It’s like red, brown or black. Like that’s what we care
Unknown Speaker  24:24
or khaki, I meant Klay
Unknown Speaker  24:29
whatever fun facts Oh. So your colon actually sees like 10 liters of fluid every day. And it’s like really good at absorbing water. So it absorbs like nine liters of fluid every single day. That I don’t know. I find that to be a fun fact that is.
Unknown Speaker  24:48
I’ll supplement that fact with another fact. You generate a leader to a leader and a half of mucus a day between your nose and your mouth and that gets swallowed. That’s a lot. That’s a lot. So yeah, grow. That’s the whole post nasal drip and people like but I feel this mucus dripping down the back of my throat. Yes, it’s called us I know it’s called sorry mucus, ciliary flow, the sinuses and the nose make mucus it’s pushed post yearly, by the cilia purpose and on purpose in a very intentional way in a very specific way. Actually, you can, if things go off course, you can end up with something called recirculating mucus and that can be a night as for a sinus infection, so it ends up getting swept back post here early and then you swallow it. So all of that mucus is supposed to is post nasal drip so it is in fact,
Unknown Speaker  25:40
normal.
Unknown Speaker  25:42
Now it can be abnormal in the same way that you were you were saying about the GI tract right like if you absorb a little too or I guess a little too much like if you’re dehydrated, right like you take a little too much water out of your still you’re going to get constipated, very hard to lose are a little too late. Just a little bit too little. And then the end of the diarrhea, you know, people are very sensitive to the sensation of mucus dripping down the back of their throat, so a little little too much in a cold and it can really bother you. Or, if your mouth is really dry, you end up with this very viscous mucus and people end up spitting and thinking that they’re making too much mucus, but really, it’s just their throat is dry. So it’s a little little otolaryngology aside for you. So just another aside, please stay tuned, because Dr. Marina will be back with another episode if you’re enjoying this one. And I hope you are because I certainly am. About more more fun and interesting gi facts, but we’ll get a little more technical in the next one. And we’ll talk about reflux and we’ll talk about other other workshops. It may get controversial, and it will certainly get exciting. But for this episode, I wanted to talk a little about gluten. Yeah, we’re going to be a little controversial now. So So Not good, not not celiac specific Because that is a my understanding it is a pathology based diagnosis, right?
Unknown Speaker  27:07
Absolutely. You need to have to auto biopsies showing vilest blunting to make a diagnosis of celiac.
Unknown Speaker  27:14
Okay. But what about all of those other patients who complain about gluten sensitivity? And are celiac negative and just to be clear, gluten is a protein that’s present in wheat. And it’s what gives dough its stickiness and in doing this
Unknown Speaker  27:39
so, for the bait Baker side of me, there you go.
Unknown Speaker  27:43
Nice. So, um, yeah, so there are a lot of people that are sensitive or intolerant to gluten but don’t necessarily have celiac. And that’s because, you know, we’re not really made to digest gluten all that much and we end up to and way more than we can handle. And so actually most people would probably feel pretty good on a gluten free diet. It’s hard to do. But gluten is one of those things that gets fermented in the GI tract, and can cause a lot of gas and bloating and discomfort. And so there’s a ton of people that just, you know, have symptoms with gluten. But it’s actually really important to tell the difference between celiac and just gluten intolerance or gluten sensitivity. Because people with celiac, you know, there’s actual damage happening to the small intestinal lining, that can lead to a lot of other problems like osteoporosis. The chronic inflammation in the gut can lead to things like small bowel adenocarcinoma or small bowel lymphoma. And so it’s really important to kind of Make the diagnosis does this person actually have celiac disease? Or can they just not tolerate gluten? And that needs to be done before they go on a gluten free diet. So a lot of times primary care doctors will have their patients go on a gluten free diet or or patients themselves or their read on the internet and they’ll go on a gluten free diet and they feel so much better and then it’s really kind of hard to convince them Well, okay, go back on. So we can
Unknown Speaker  29:26
have this loaf of bread, right? That’s gonna make
Unknown Speaker  29:31
me uncomfortable, right and so we can take a piece of so we can put you through a procedure where we actually take a piece of you and give it to some other guy to look at under slide.
Unknown Speaker  29:41
Right. It’s it’s really hard to convince people to do such things but it is important to know the difference and then plus it has you know, implications for families because it is hereditary. So, if patients do have celiac then we would recommend getting their kids tested and stuff. So it is important to kind of sort that out. But yeah, lots of people just, you know, don’t feel too good on gluten club cause bloating, abdominal discomfort, diarrhea, gas sounds
Unknown Speaker  30:10
a lot like lactose intolerance, right? Like we haven’t evolved to consume the amount of dairy products that we do in our modern society. And so this is our body telling us that you know what, a little bit good for you fine. Keep the you know, vitamin A and D levels up but
Unknown Speaker  30:34
the volume that you’re eating? Yeah, I’m sorry. I’m sorry, saying
Unknown Speaker  30:38
you can overwhelm your lactase, you know, the enzyme on your small bowel Villa that kind of break down the lactose. And actually, as we age, the lactase goes away. So, like for certain, like European.
Unknown Speaker  30:57
derive, derived, I guess European ancestry
Unknown Speaker  31:01
said yes descent Thank you.
Unknown Speaker  31:05
There’s a very high rate of lactose intolerance like as we as you age, so by the time you’re like in your 70s I think it’s like something like 60 to 70% of like Eastern European Caucasians will have lactose intolerance. So it’s very common as we get older.
Unknown Speaker  31:20
Hmm. And can you up regulate it? Like by fighting the good fight and just kind of pushing through
Unknown Speaker  31:26
just pushing through and eating more and more cheese?
Unknown Speaker  31:31
No, no, no.
Unknown Speaker  31:34
Yes, unfortunate.
Unknown Speaker  31:35
It is. It is because I love a good
Unknown Speaker  31:38
cheese. Yeah, but fortunately, I have not yet developed lactose
Unknown Speaker  31:42
intolerance that will be associated cheeses are some of the best. My wife is Swiss. So we every so often, we’ll have a good stinky cheese. It smells like feet, but it’s delicious.
Unknown Speaker  31:56
Yeah, so the the good thing though, is that there’s like a ton of gluten free products out there and they don’t taste that bad. So, you know, for the people that it does bother are the people with celiac, there are good options now, whereas like a decade ago, people were it was hard. There were
Unknown Speaker  32:10
no yeah. Yeah. I mean, there’s restaurant menus and yeah, it’s hopefully for the lactose intolerant community. There will be a similar revolution. But
Unknown Speaker  32:27
you can just take
Unknown Speaker  32:29
you can do that. Well, Danielle, this has been Dr. Marina. This has been very informative. Thank you very much for your time. I appreciate it. It was a lot of fun. I can’t wait to have you back for future episodes.
Unknown Speaker  32:44
Cool. Thanks for having me brand.
Unknown Speaker  32:51
This was Dr. Bradley Block at the physicians guide to doctoring. Find all previous episodes on iTunes, Stitcher or wherever you get your podcasts and register review. If you have something nice to say. You can also visit us on Facebook search physicians guide to doctor
Transcribed by https://otter.ai

Poopisode

The ideas expressed on this podcast are those of the interviewer and interviewee and do not represent those of our respective employers.  This podcast is intended for medical professionals.  The information is to be used in the context of your own clinical judgement and those on this podcast accept no liability for the outcomes of medical decisions based on this information.  As the radiologists like to say, clinical correlation is required.  This is not medical advice and even though the magic of podcasting may make it seem like I am speaking directly to you, this does not constitute a physician – patient relationship.  If you have a medical problem, seek medical attention. 

Introduction to Advocacy for Physicians

The ideas expressed on this podcast are those of the interviewer and interviewee and do not represent those of our respective employers.  This podcast is intended for medical professionals.  The information is to be used in the context of your own clinical judgement and those on this podcast accept no liability for the outcomes of medical decisions based on this information.  As the radiologists like to say, clinical correlation is required.  This is not medical advice and even though the magic of podcasting may make it seem like I am speaking directly to you, this does not constitute a physician – patient relationship.  If you have a medical problem, seek medical attention.

This is the transcript to the episode. This transcript was created by a talk to text application and the function of having this here is to improve the page search engine optimization. This transcript has not been proofread, so please listen to the episode and don’t read this. The information contained herein will inevitably contain inaccuracies that affect that quality of the information conveyed and the creator of this content will not be held liable for consequences of the use of the information herein.

Unknown Speaker  0:06
Welcome to the physicians guide to doctoring Episode Two, Introduction to advocacy, where I interview Jennifer Tassler, an expert in medical advocacy, and currently the Director of Policy and programming at the associated medical schools of New York, where we discuss how physicians can do a better job of advocating for ourselves some easy ways to get more involved, and why donating to a pack is important and where the money actually goes, as well as some high return on investment activities for advocacy. So the lowest effort with the highest yield the ideas expressed on this podcast, those are the interviewer and interviewee and do not represent those of our respective employers.
Unknown Speaker  0:47
Without further ado, Jennifer Tassler
Unknown Speaker  0:53
Jennifer Tassler, thank you so much for coming on the podcast today. I’ve known Jennifer for Quite a few years, I actually did residency with her husband, which is how I know her. And we’re going to be speaking today about advocacy for physicians, but certainly being married to a physician doesn’t make her an expert. But nor does being a friend of mine, but she has quite a background in it. And I think she has a lot of interesting and useful information to share with us today. So, Jennifer,
Unknown Speaker  1:24
well, thank you for having me, I appreciate it. And I’m always happy to talk about ways physicians can advocate for themselves in their profession, especially since I am married to one and his profession is also my livelihood, in many ways, um, so my background is that I’m an attorney, but I’ve never litigated I went directly from law school to the Congressional Affairs Office at the Food and Drug Administration, and learned a lot about politics and what makes someone effective and getting to the people who can make things happen. And from there, I went to the American Psychiatric Association which is the Industry Association for psychiatrists. And it has many analogs and pretty much every medical specialty and allied health profession. Everyone’s got a society or sub specialty society. And so this one is for psychiatrists, and I did a lot of Congressional Affairs as well as federal affairs sort of regulatory policy there. And in that role, I did a lot of working with physicians in advocating for on payment issues, scope of practice, issues around patient issue. Now, consumer rights organizations, and we did a lot with patient advocacy, especially in psychiatry, a lot of their patients don’t necessarily have the means or the ability to advocate for themselves. So that’s something we did a lot of there. And after that, I took a little break when I had children and Andrew did his fellowship and I’ve recently gone back. We’re now in New York and I work for the associated medical schools of New York. Also doing government affairs, I do more state side stuff a lot with New York state politics, and some federal and a little bit of city work. So again, in that sense, I’m advocating for the medical schools of New York State.
Unknown Speaker  3:22
Wow. That is
Unknown Speaker  3:26
quite a bit of experience that you’re bringing to the table today. So sounds like also you’re very busy. So again, thank you for taking the time especially with with the children at all. Thank you for taking the time to talk to me today and talk to us. So right off the bat, as a physician, I have gone through tons of training as you experienced yourself. Lots of long hours, lots of studying and I feel like I shouldn’t have to advocate I’ve I’ve done all this work, I really shouldn’t have to advocate for myself. Why? Why is this in necessity? And I feel like a lot of physicians are going to feel this way. I just, I don’t feel like I should have to. Why is it that I do?
Unknown Speaker  4:17
I heard that a lot, especially when I was at a PA that, you know, this isn’t what I do. I hear this a lot from Andrew as well that you know, I went to medical school so I can operate so I can take care of my patients. And this isn’t what I do. I think there’s a lot of rightfully siloed stuff that this is not my expertise. I don’t you know, somebody who is better equipped to handle this should do it. And that is true to a certain extent, but it’s also not because while we do have advocates for you, I mean your specialty societies, the or medical societies, your hospitals, or advocate for you. You are your own best advocate. You are the person who is in the office or in the operating room or out in the VA wherever you work, dealing with patients dealing with billing, dealing with office staff, insurance companies, you are the best person to advocate for yourself your experience, the way you can talk about what you do and how you do it is much better coming from you than it is coming from me or anybody else who does this work. And we can be there most of the time and relaying that message but hearing from you is invaluable to any elected official or anybody who’s making any kind of change. They really, it drives home the point of, you know, what you do, what you’re experiencing, what the problems are, how they can help you more than anything. And to that end, especially with elected officials, you employ them and they should be working for you. I mean, everybody these days needs to speak up and say What affects them? And for a lot of physicians, a lot of things affect you, and not just, you know, payment policy or regulatory issues. But everything I mean, we deal with dealt with things about building codes, how they affect physicians, I mean, it’s really very broad. And each person has their own slightly smaller or personal point of view that they can get across better than anybody else can.
Unknown Speaker  6:30
So if I’ve never even dipped a toe in this arena at all just seems very abstract. I recognize that I can call my Congress person but I’ve never done that before. I don’t know the issues. I don’t know. You know, what, what’s a good first step for someone who’s never really been involved before?
Unknown Speaker  6:49
I think the best first step is to take a look at what your specialty society is doing. I think that that’s sort of the best way to localize some of your issues, I mean, there may be, especially if you’re in a smaller specialty, like I’m thinking I’m thinking not internal medicine or general surgery. But even those, you know, if you go to their website and see what they’re advocating for, maybe there’s already something going on about this, there could be an alert out or something like that. And to and I think one of the most important things that physicians can do just to be just a pure head count, is to join your specialties society. I know that when I was with the psychiatrists, you know, every comment every letter, everything we say, says how many members we have, and that makes a difference. So the people who read those letters, they want to know that there are 43,000 people who want us to speak up on an issue. And just from just a pure numbers perspective, it helps if you are a member that you can stand up and be counted among those physicians. I think I think that’s sort of like the simplest, easiest thing you can do, and you get journals. So that’s, you know, When, when, but there’s also, I mean, it also helps to be in touch with your specialty society. I mean, I think a lot of people, particularly in the larger ones that have a presence in Washington, you know, they don’t necessarily we have, you know, our general issues that we work with, with, you know, a lot of combined meetings and things we do across specialties. But we need to hear from our members, what’s affecting them. I mean, I used to get calls sometimes from somebody saying, I’m having a problem with Medicare. And you know, this carrier isn’t doing this and I’m not getting paid and what’s going on and they can make a call for you and either find out what’s happening or see if this is a larger problem. Sometimes we will put our alerts and ask if you know something else, if anyone else is experiencing this and if it ends up being a larger problem. You know, then you have the full force and effect of a specialist society going to bat for you. Another thing I think that is very key about your specialty society is that they do outreach to you. So when you said like, I’ve never called my congressional office, I wouldn’t know where to start. I don’t want to call them and just complain about, you know, the fact that I’m not getting paid this much for an office visit versus that much. The specialty societies will often do what they call action alerts, or they’ll send you an email and say, this is an issue that’s happening. There’s a vote coming up on the floor, there’s a bill we’re pushing in Congress, call your legislator, and they will often give you not only the phone numbers, the names will give you a script, they’ll tell you what to say that’s in line with their position and you can either act on it or not. And you know, that’s up to you, but it’s a good way to get connected plugs in it also tells you what they’re working on. Because if they’re working on a bill related to scope of practice, and that’s something that, you know, now that you think of it, that’s a problem for you, you know, there, there’s an easy way to get access to the issues, the language
Unknown Speaker  10:19
and the way in which you can be effective.
Unknown Speaker  10:23
I just for emphasis, I just want to reiterate some of the things you just said. So one, one thing I thought was important was be a member of your specialty society. It sounds like that is literally the least you can do at least you’ll be counted in the roles. When your advocates go to advocate for you, you’ll be one of many and you won’t be counted if you’re not a member. So their voices are more likely to be heard if they represent more people, right. So if there is an issue with scope of practice between nurse practitioners and in Internal Medicine. And there are more nurse practitioners that are a member of their specialty society, they’re going to get more of a voice from their Congressman, or they’re going to more likely to be heard by their congressman than the internal medicine doctors, because there aren’t as many of them. So in order to be counted, you need to be at least be a member of the specialty society. And the other thing that you said that I think was hugely important was one thing that I think can get you the biggest return on your investment as far as your time goes, is, if you’re involved in your specialist as I do, at least you’re you’re you’re getting their emails, they can give you these talking points, they can tell you exactly what to say exactly who to say to. And if you agree with them, it’s just a phone call. You can make that call on your way to work. It doesn’t take that much of your time. And you can and there aren’t that many people that are calling their Congress people about scope of practice issues, right, right. If it’s gun control, Everybody’s getting on the phone and one way or another, right? Like, you’re going to be one of many, many voices. But if it’s a scope of practice issue or reimbursement issue, which, as you told me in our pre interview, phone call, these are the two biggest issues scope of practice and reimbursement. So you’re you’re going to be one of very few voices getting on the phone with your congressperson who might then say, you know, what I heard from Dr. Block in my district, and he is very upset that you have people that are not very well trained, we’re going to be treating their patients, and it’s going to be putting them at risk. But if you’re not making that phone call, all they’re hearing is well, there aren’t that many practitioners out there and there’s issues with access to care and we need more boots on the ground. So we need to give more people prescribing privileges or whatever the issue is with their they’re going to hear the opposition they’re not going to hear you which really gets to why we need to do this exact, you know, You know, at the beginning of the call, you know, begrudgingly, I shouldn’t have to advocate myself. But the fact of the matter is, don’t hate the player hate the game. Because the game is out there. And if you don’t admit that it’s out there, then you’re just going to put your head in the sand, then then your scope of practice is going to get encroached on and your reimbursement is going to continue to go down. And administrative costs are going to continue to go up and you’re going to be very unhappy, and you’re going to complain, you’re going to be complaining to the wrong people.
Unknown Speaker  13:30
True. I mean, it will certainly fall on deaf ears if the years are not being open to that message. And I think the other thing is that, especially aside as we often target it, you can make the most effect. So a lot of times they’ll do what they won’t, they’re not going to do a blanket announcement, a blanket action alert for everybody on a very specific issue where only, you know, two states have senators that are on this committee that’s voting on a bill coming out. I mean, those tell you. So if you’re getting that alert, you are probably more important at this juncture. So, you know, those are really areas where you can make a difference. Again, like you said, large national issues, everybody’s flooding the phones for something. This is something where you can really get into into their office and get a bug in their ear about something that can really affect them that this boat is coming up tomorrow. I need you to vote now. And this is why and I think, you know, you’re probably not going to get the member but a staffer can send that along or you can call the district office. It’s not always about I have to be in Washington, I have to be, you know, in their office meeting with people glad handing that’s not really what it’s about. It’s about just making your voice heard. Those things are all good, but certainly for somebody who’s busy, a physician who’s not interested in going down to Washington and doing Advocacy day, this is a great way to start and a great way to make your voice heard.
Unknown Speaker  15:05
So I think there’s there’s an issue that some physicians have with the AMA, right, the group that’s supposed to represent all physicians, and there is a thought that they don’t necessarily represent my interests some of the time. Maybe they don’t represent my interests most of the time. Like, let’s like they’re advocating for universal health care. Let’s say I’m a physician who doesn’t agree with that. I’m certainly not but you’re, you’re finding a reason to disagree with them. And so you don’t want to join the society, right? You don’t want to join just I mean, your specialist is is it is a different story, because they’re more focused on your specific needs. But as a specialist, you know, the American Medical Association is, is certainly they have many more generalists in there as members. So that’s going to be more of their concern. But But if if, if I do I’m a member of the AMA, how do you explain to a physician that it actually is? And is it actually in their best interest to be a member of the American Medical Association? If their concern is that they don’t feel like they’re advocating for their views?
Unknown Speaker  16:18
Um, I would say that’s tricky. I think. I mean, I would certainly say that most physicians I know who are not generalist are not members of ama. I think being a member of your specialty society is probably the most important and I know at least for Andrew who so specializes, he’s a member of those sub specialty societies. But again, like you said, ama does not represent the interests of all physicians. It is very broad, and to expect them to cater to a minority is difficult. However, I will say that and they did a certainly when I was in DC they held multi specialty cold So we often did meetings where it would be literally every specialty you could ever think of in medicine sitting around a table, talking about our issues, and sometimes people would speak up and say, my members are not for ACA, you know, we’re totally against it. I hear from them all the time about this problem, this problem, this problem. Others specialty societies would say members are for, you know, majority we’ve decided, I mean, there’s a board structure within each messages society that sets their policy. And so in that sense, you are being represented at the larger table. And a is very effective at getting very high level policy interests of physicians known. I think, if you feel strongly about being a member and you do feel like they represent you, I would certainly join. I don’t know if I’d say for everybody, it’s the right choice and for a lot of people in It’s simply expensive and not necessarily worth it in other respects. But I think, like I said, joining your own specialty society is very important. And I think, you know, you’re certainly always welcome to make your voice heard at ama, I’m sure they hear from lots of people all the time. But again, you’re even if you are not a member of ama, if you are a member of your specialty society, your voice is being made her around their table. So those interests are percolating up and may not make it to their policy decisions, but it is discussed internally, I would say.
Unknown Speaker  18:43
So there is a way for some of these smaller specialties to be heard. Yes, a massive organization like that, but
Unknown Speaker  18:52
and we often do reiterating that point,
Unknown Speaker  18:55
right. I mean, and a lot of times, a lot of the work we did was on if it was abroad. issue that affected physicians. Ama would circulate a letter to the specialty societies and we can either sign on or not sign on. And in that sense, its safety in numbers, there’s it makes it very clear that there are a wide range of physicians specialties that are against or for certain policy and that can be very effective in and of itself. And there are different reasons why MA would, you know, put out their own letter versus trying to get a consensus. But in that sense, there is a way to work together to try to make our policy decisions known and for physicians, I think that you know, there are certain things where within specialties there can be like very, very strong disagreements over you know, reimbursement policy, or practice models or me There, there are crazy crazy amounts of distinctions between different specialties. And so when they can get consensus they do and when they can’t, you know, sometimes they don’t sometimes they’ll be smaller letters like sometimes groups of like sometimes the surgical subspecialties will sign on to a letter or, you know, American College of Surgeons will do something similar will they’ll try to gather up all the surgical societies or there are there are ways to sort of band together to be more effective, because like you said, it’s it’s the same type of thing or if it’s one, it’s, you know, it’s hard sometimes to rise above the noise. But when you get a bunch together, people start to notice. So there are all kinds of different ways to do it. But I think that’s why I think the specialty society is so key because it really helps your interest. I think that’s the best That’s going to be the best fit for you probably. I mean, there are plenty of people. I mean, I, I encountered plenty psychiatrists who would say, I’m not a member of APA, I have no interest in joining. They don’t speak for what I want that, you know, I have no interest and and that’s fine. But for the larger group, it does help to be a member. Well,
Unknown Speaker  21:20
it sounds like it sounds like for that individual, they should get on the phone with their advocate in the specialty society, right, they should become a member and become engaged. Because if they feel like their voice isn’t being heard, there’s a fairly easy way for their voice to be heard. Yeah, joined the specialty society. And you get on the phone with the advocate, as you said, you know that your Congress person works for you. Well, if you’re a member of the society, then your advocate works for you. And it’s true. And the only way that they’re going to be aware that you’re disgruntled with the position that they’re taking is to get a seat at the table. Absolutely. So all the more reason to be to be a member of the specialties. But what about what about the political action committee? So so every so often we get these letters in the mail from our political action committee that looks like our dues are due and it’s, it’s a little deceiving. Should I say, the way that it’s worded because it makes it look like oh, it’s this is a bill have to pay this. When really, it’s the elective news for the political action committee. And so, you know, you said the least you can do is to be a member of your specialized society. highest return on investment is to actually get their alerts and get on the phone. Um, so does does the pack fall somewhere in between like, what’s what’s, what’s the difference between the specialty society and the pack? It seems like the pack is the advocacy arm of the specialty, is it solely I’m a member but I don’t donate what’s Could you clarify that for us?
Unknown Speaker  22:52
Sure. So a pack political action committee is sort of a it’s a fundraising tool. So typically, when you contribute to a pack. It goes into a fund that helps pay for fundraising for elected officials. So often a member of Congress is running, they need to raise money. I mean, the joke, our pack directories to make it a PA is what’s the first thing a member does when he gets the Congress, he says he needs to raise money. That’s what he has to get reelected. So you know, the pressure to constantly fundraise is immense. And they’ll often hold fundraising activities where the member of Congress will meet with people to ask for donations. And so a lot of what those things do is it helps your advocates get a seat with a member bend their ear for a little bit at an event. And, you know, I will say there’s a quid pro quo at all but there is certainly access that is gained by donating to a members pack. And it can be it can be a little deceiving in some ways I’m you know, I think the specialist as eyes that I’ve worked with have all been more than above board and but there is like a, there is a perception. I think that it’s it’s not and I don’t think it is. But it definitely helps your advocates meet with members and have your concerns rise to their level. And then when we talk about staff hearing about things, and this is a direct access with the member and we’re also another thing I talked about the specialty societies is that they often band together for pack events. So often, a pack event would be a round table with a number of medical specialty societies meeting with a member of Congress or another elected official and it’s your chance to Talk about issues that are concerning you. And I mean, it’s a very effective tool in that you have an audience and you can talk freely about the things that are affecting your members and really get a chance to make a difference. I think there are certainly different ways that packs are run, like, you know, across not just medicine, but you know, across all packs. But the way our work to API is that, you know, all the donations coming from members were 100% used for donations, political donations, and that I think the staff time was funded elsewhere. So that’s something I think is really important. And I know it’s important to our members that like they knew that their dollars were going specifically to where we thought we can make the most impact to help the People who are going to help us get elected stay in Congress and have that opportunity to talk to them in that way. You know, I think if you’re inclined to donate to a pack, this is optional. I know, like you said, it might not seem optional, but it usually is.
Unknown Speaker  26:20
But you can
Unknown Speaker  26:23
certainly ask anybody, your pack should be able to answer your questions about where the money is going, what it’s doing, it’s all public information. And you can ask them what goes on or what they’re talking about, or a lot of times we sometimes have members come to a pack event, which is again, another great way to make your voice heard is that you know, if their special society knows that you’re interested, and you’re, you know, concerns or something that echo our policy and you want to make a difference, sometimes we would have in district meetings with these members, and we would bring Physicians with us and that’s another way of just making your voice heard and it comes to you in that sense. But, you know, you could, if you’re interested, you can give $25 or $10. I mean, it’s really not you don’t have to be giving tons of money to a pack if you don’t feel the need. And if you don’t want to, don’t donate, it’s really know something.
Unknown Speaker  27:26
Something that I want to clarify actually comes from our previous conversation before the interview was that in order to be counted, it’s being a member of your specialist society. It’s not being a member of your pack. I was under the impression that that you’re you’re not counted as an individual so to speak, like you that your pack doesn’t speak for you unless you’ve done it to the pack but the pack speaks for you. If you remember this specialist. This is everything that goes to the pack is icing on the cake. And one of the themes of this podcast is trying to get the highest return on investment and From what you were just describing, it sounds like the job of the advocate is to make sure that the money that gets donated to the pack gets the highest return on investment. So so they’re they’re going to make sure that it’s going to the trickiest issues, the most important issues. And the only way to make sure that your issues are seen as the most important issues or are up there is to donate to the pack, and then go to the meetings and make sure your voice is heard or the very least donate to the pack and then get on the phone with your advocate because then, you know, they’re there. Your voice then carries more weight. It’s an unfortunate situation that that money talks like this. Donate the player hate the game. This is this is the way it is, you know, until we get money completely out of politics. It will continue to be because the the Congress people are the ones that decide issues like this and the only way to get a voice in the room is to make sure that your is to make sure that you are donating. So, again, it circles back to the issue from the very beginning, it seems like we shouldn’t have to, but we do. And if we don’t, someone else’s, and their interests are going to be heard over ours.
Unknown Speaker  29:13
And it’s usually seen, I mean, there are sort of, you know, some people know, like size of packs. I mean, like you said, that’s not necessarily a number of people, although, I’m sure the societies keep track of, you know, percentage of members who donate to the pack, and they keep all kinds of data. But it does matter in terms of how big the pack is relative to the society. I’m in some specialty societies, you would think they’re very small societies, but they have huge packs. And that, again, it’s a it’s a similar sort of numbers deal where like that can make a difference in doors that open and, you know, places you can go and people you can talk to, unfortunately, but True. And, you know, I think that it does help if you want a strong society that’s going to advocate for your interests. Helping them in any way you can, is helpful. And I think that even just a little bit is helpful. And, you know, like we used to do something you can always do, like I said, you know, the specialist society, people work for you and you. We used to have meet and greets, at the our annual meeting, where we would the government relations staff would be able to on hand to talk about what the pack does. One why it’s important to donate. And it really, I think it did help put people’s minds at ease because there is, I mean, like, we’re sort of dancing around this issue. It feels a little slimy. But, you know, I think that a good government relations staff is not going to do anything that’s, you know, shady and it really does help. I mean, there are don’ts.
Unknown Speaker  31:05
Not shady, shady. Oh, this is just how the system works and
Unknown Speaker  31:09
the system to the
Unknown Speaker  31:12
to the uninformed physician. Yeah, it certainly seems that way. But I guess just watch a couple episodes of House of Cards or something like that. Right. But okay, maybe not that but but. But the reality is, this is how this system works. It’s not slimy. It’s not underhanded. It’s just, you’re right. If you’re in the House of Representatives, you get elected every two years. And as soon as you’re elected, you need to start fundraising for that for the next election. Right. It’s just an unfortunate reality of having money in politics. And so in order to get a seat at the table, their money has to, they have to in order to get elected, they need the money in order to have your voice heard. You need to, I guess provide them with hope so but that money That’s just Yes, it’s just, this is just the reality of the situation. Well, this was extremely informative. Thank you very much for taking time out of your busy, very busy life, just to circle back to to the point, big return on investment for getting involved in the specialty society and then getting on the phone whenever they recommend because they they value the physicians time. They know that we’re very short on it, and they’re not going to ask you to get on the phone with your congressperson unless they really feel like it’s going to make a difference. In order to do that you have to be a member of your specialty society. And that donating to your pack is important because it does allow your voice to be louder than it would be should you not be a member and that all of your advocates are available to you. So make sure that if you have an issue that you feel is not being adequately addressed and then get on the phone with them rather than complaining which which can be a contact sport for many people. Rather than just complaining, do something about it and I think you’ve made it very clear how we can do it. And thank you very much for your time.
Unknown Speaker  33:08
Anytime. My pleasure. Thank you for having me.
Unknown Speaker  33:15
This was Dr. Bradley Block at the physicians guide to doctoring. Find all previous episodes on iTunes, Stitcher, wherever you get your podcasts and register review if you have something nice to say. You can also visit us on Facebook search physicians guide to doctor
Transcribed by https://otter.ai

Introduction to Advocacy for Physicians

The ideas expressed on this podcast are those of the interviewer and interviewee and do not represent those of our respective employers.  This podcast is intended for medical professionals.  The information is to be used in the context of your own clinical judgement and those on this podcast accept no liability for the outcomes of medical decisions based on this information.  As the radiologists like to say, clinical correlation is required.  This is not medical advice and even though the magic of podcasting may make it seem like I am speaking directly to you, this does not constitute a physician – patient relationship.  If you have a medical problem, seek medical attention.