Episode Transcript
[00:00:05] Speaker A: You float like a slow pen look on no hands upon no frame no shame Numb me up like Cane can't focus Shake again which moment makes a man? Cuz I'm hoping it just begins.
[00:00:18] Speaker B: Welcome. I'm Dr. Robert Groves, your host for the Groves Connection Podcast. The Groves Connection brings you intimate conversations with pundits, providers, patients, leaders, leaders, and laypeople, all to help us understand a contradiction.
How can our healthcare system be both magnificent and yet so deeply flawed?
We're going inside Healthcare to talk candidly with those who know what they have to say. May delight, surprise, frustrate, or at times, even anger you.
But I invite you to get curious and listen to the truth about healthcare and those who want to fix it.
Maybe the answers have been there all along.
We just need to make the connection.
Are you ready to connect?
[00:01:15] Speaker A: Robert Groves, welcome to the Groves Connection.
[00:01:19] Speaker B: Thank you so much. I'm so happy to be here. I'm a little nervous. I'm still admit we've been wanting to
[00:01:24] Speaker A: get you on the show for a really long time. This is such an honor. This is episode 50 for us.
[00:01:29] Speaker B: Episode 50? Yeah.
[00:01:30] Speaker A: For those of you that don't know, I'm Alden Groves, son of my interviewee here. And today we're kind of flipping the script a little bit. I'm going to be interviewing him, and he's going to be under the gun at this point so that we can kind of get a feel for. Who is this guy that's been running
[00:01:47] Speaker B: this podcast anyway, for the viewing audience? Alden is really the one that makes all this possible. He is. He's the producer, essentially, at this point. He does all of the sound, all of the technical, he does the blurbs. I mean, I have only been responsible for doing the easy part. So you are meeting in person the guy that is really the Groves connection, and that is Alden Groves.
[00:02:10] Speaker A: I mean, not to get too sentimental, but in a way, this is the gross connection.
[00:02:13] Speaker B: There you go.
[00:02:14] Speaker A: You do so much. You just did a conference for hpn, is that right? Yes, but I want to go way back.
[00:02:22] Speaker B: Oh, my goodness, this. This sounds so familiar. Okay, fair enough.
So I grew up in a little town in South Georgia. Not that little was about 100,000. Depending on where you're from. That can sound big or little.
60,000. At the time that I grew up in it, it's called Albany, Georgia, and I was one of three kids. I have an older sister and a younger sister, and it's kind of two up and two down.
Two years older and two years Younger. My dad was a primary care physician in South Georgia. And, you know, there are lots of experiences that I remember from that time in my life, one of which was busing. I mean, there was a. It was a tumultuous time.
[00:03:05] Speaker A: Yes.
[00:03:06] Speaker B: In the, the 60s and early 70s, there was a, A move to integrate school systems because the issue was that there was disparity. Right. And all the taxes went to support white schools, and black schools didn't have the resources to provide the same level of education. That was the argument, and I think it was a good one. And so in an effort to force integration, basically we got assigned to schools, and if necessary, you would be bused across town to a school.
As you can imagine, it was a contentious issue with a lot of folks in the south in that day and age.
My dad, primary care physician, did some interesting things. For example, he was one of the first docs in South Georgia to have a mixed waiting room so that there was no separation of white and black patients.
One water fountain, one restroom, and so huge. Yeah, it really wasn't. It defined a lot of his, his career. And it certainly left an impression on me as we were growing up, because that was not the sentiment in a lot of the south, we were always fortunate to have horses around.
[00:04:21] Speaker A: Interesting.
[00:04:22] Speaker B: There's something very calming about horses. I'm not sure how to describe that. In fact, when I originally moved to Colorado, I thought that I would have a horse property. It just never happened.
But that was an aspiration. One of the reasons I moved to Colorado, I wanted to be a cowboy.
[00:04:37] Speaker A: Love that. Love that. So you're talking about busing. This is in elementary school for you, or is this throughout middle school? What is the range?
[00:04:43] Speaker B: Yeah, it started in elementary school and then, you know, was in full swing by the time I went to, to high school. So that, that was the.
[00:04:54] Speaker A: And this is all in Albany. Elementary school, middle school, high school, with one caveat.
[00:04:58] Speaker B: I mean, there was a, an interruption in the process very early on in my childhood where I got into some trouble.
I was a little bit of an unruly child, if you will. In fact, I was officially declared as such.
[00:05:14] Speaker A: Interesting.
[00:05:15] Speaker B: And I actually graduated from Cooper City High School in, in Davie, Florida, which is right outside of Fort Lauderdale.
So that is an interesting, interesting part of my, my childhood. I have to say that the program that I attended has taken some bad raps over the years for the things that they use, but it was transformational for me. It did really wake me up and shake me up.
[00:05:41] Speaker A: Do you feel like there's some aspect of your life prior to that, this sort of unruly kid. Do you feel sometimes like you're bringing that unruly. Do you feel like an unruly adult ever? Do you feel like you're bringing that into your work and into your life?
[00:05:55] Speaker B: You know, there is an aspect of my personality that is contrarian and disruptive and, you know, wants to fight against the status quo.
And I, I think over the years what I've learned is that that's great as long as you're able to manage and direct that energy in constructive ways.
And so, yes, it is definitely a part of my personality, but I hope that I've learned how to manage it and direct it more efficiently and to better ends than I, I could as, as a young adult with an immature brain.
[00:06:33] Speaker A: Middle school, what was that like for you?
[00:06:35] Speaker B: I never, I never was a fan of school. I didn't like it. I, I somehow I didn't fit in with the rest of the group. I mean, I, I, I, I like sports and I participated in sports at least up until, until middle school, but I never felt like I fit in with the middle school or high school crowd. I always felt some extent ostracized by that group. And so it was not a comfortable thing for me.
Now I enjoyed certain teachers very, very much and was really drawn to literature and history and biology and enjoyed that aspect of it. The other thing I think that influenced my, my school years was I was really hard of hearing even back then. In fact, it was diagnosed in.
There used to be a program called Easter Seals that would do screening in, in school for hearing problems. And they diagnosed me with a hearing problem.
And at the time I simply refused to, to do anything about. In fact, I didn't never do anything about it until I was out in practice for a few years when I was kidnapped by my team and forced to get hearing aids because they were tired.
What, huh.
[00:07:54] Speaker A: Interesting.
[00:07:55] Speaker B: Class was not very rewarding for me because I quite literally couldn't hear what people were saying.
[00:08:02] Speaker A: That's interesting. I also think there's something to be said there for, I think people might attribute that to something other than you literally not being able to hear them. I think that that happens a lot in school where the teachers just don't have the bandwidth to address every individual person's needs or even keep track of them. So they maybe just think that you're, yeah.
[00:08:21] Speaker B: Not paying attention. Something I got a lot and it was, you know, I'm trying to, but of course, you know, if you try for a while and you still can't hear. You just kind of tune out and read something or, you know, doodle or whatever else. And that did get me in quite a bit of trouble.
[00:08:36] Speaker A: Okay, so at what point do you become, obviously, you said your dad was a primary care documentary. At what point did you become sort of aware of and interested in healthcare as a potential trajectory for your life?
[00:08:48] Speaker B: I really always wanted to, you know, to please my parents. And I was proud of my dad and he was well respected in the community as a primary care doc. And I heard the stories, you know, patients would tell us all the time. Oh, I love your dad. And he's this and he's that. And when I was a kid, probably when I was in the, you know, 9, 10, 11, maybe 12, I used to actually go on house calls with him. And I'd go into the hospital on occasion and do Morning Report. And it's interesting, back then, the.
The hospital, which was not an academic hospital at all, this is Albany, Georgia, but they used to have, every morning they would gather at 7am for morning report, and you'd have all the primary care doctors, all the specialists in one room discussing the cases that came in last night. And, you know, there would be, they call it curbside now, but there would be recommendations from the specialists. And, you know, do you think I need to see him or. I think you should see him or just advice on how to manage those patients.
And so that was an interesting time.
And, you know that the house calls. There. There was one episode that I remember pretty vividly and I talked about it in AI Met, where we visited a patient of my father's who was also essentially a friend of the family and another horse person, if you will, they had horses. And we had interactions in that regard, but he had a real challenge with alcohol. And I remember that we were at Morning Report and then my dad pulled me aside and said, we, you know, we. We need to go take a trip if you want. I hope you're ready for this, is what he said. And this was a big man. I mean, the man that my dad was going to see. He was probably 6, 4, 6 5, you know, 220 pounds, something, maybe 250.
And he was crumpled on the floor and crying. And I remember my dad, you know, nodding to his wife as he came in and nodded to her. And then he went over to this gentleman and sat down on the floor with him and just put his arm around it. That's all he did.
And of course, you know, the the patient continued to weep.
And I just remember it being so touching, and it really had an impact on me. And I thought to myself, gosh, I wonder if someday I could mean that much to somebody.
And I wonder if someday I could to be that to somebody. And so that was where my interest was, was really that's where it started.
[00:11:33] Speaker A: It's a common story right on the podcast that you point out where it's. People get into healthcare because they care.
[00:11:40] Speaker B: Yes.
[00:11:41] Speaker A: Out of high school, did you go right to college?
[00:11:44] Speaker B: That was during that period, you know, I just graduated from Cooper City High and still had a little bit of a rebellious streak in me that hadn't been completely beaten out by.
By the program. And I got crossways with my dad again and was kicked out of my house.
And so I had to go get a job. And I ended up being an assistant manager at Alums, which was, gosh, well, it's kind of like a TGI Fridays or something like that. At the time, their. Their big claim to fame was hot dog soaked in beer.
I ran into some folks at that job that told me about an opening at Pizza Hut.
And so I wound up going over to Pizza Hut as an assistant manager and then was selected as the. The guy to open up a new Pizza Hut that was near to my home.
And so I had the. The thrill of, at, gosh, I was 18, 19, something like that, of opening up a Pizza Hut and managing the staff and the inventory and so forth. So that for a couple of years before I went to college and.
[00:12:50] Speaker A: And where did you go to college?
[00:12:51] Speaker B: Center. College of Kentucky. C, E, N T.
The Old English.
It's a small liberal arts school in Central Kentucky, and it's located in my mother's hometown.
[00:13:04] Speaker A: Gotcha. And did you. How was your experience at Center?
[00:13:07] Speaker B: When I went into Center, I did apply myself and worked really, really hard and, you know, ended up with, you know, 3.89 GPA or something along those lines, and, you know, really did well academically.
I didn't completely stifle my rebellious nature, I have to admit, but I had learned what the boundaries were, if you will, what the limits are and how to manage that aspect of my life much more effectively.
It was just a really formative experience for me. I got the opportunity to.
To letter in soccer, which I had never played before I came to college. And so, you know, in a small school like that, you get so many opportunities that you don't get in a large institution. And I, you know, I was president of the Student Congress. I Was president of the fraternity.
I just got tremendous experiences and some of my favorite professors of all time, there were ones in medical school and training as well, but some people that really influenced me and shaped me and some really important mentors. Ben Feast, I remember in particular as a biochemistry professor, that inspired me to want to really learn the Krebs cycle, you know, which is a task.
[00:14:32] Speaker A: Teacher. A good teacher is worth more than words can express.
So other than having some teachers that you really resonated with in terms of mentorship, are there any names, any people that stick out, you know, know, in. In a big way at that point in your life in college is starting to kind of guide you to where you wanted to go?
[00:14:49] Speaker B: I must recognize my grandfather, my mother's father.
This is his hometown. I lived with him for, you know, my senior year in college. And he is a gentleman that I have just always respected, as opposed to my father's side, which came from an academic background and. And, you know, had all the trappings of that.
My mother's father was son of a sharecropper. You know, he was a hard scrabble. Knew how to hunt and fish and never complained about anything.
[00:15:23] Speaker A: Tough as he was a cowboy.
[00:15:25] Speaker B: Yep. Adaptable. I mean, he was a tough, tough guy, but very compassionate and. And in his own way, very warm. And I just had so much respect for him and. And wanted to be like him. So, yes, there were other mentors there. And, gosh, if you talk about college there, there were tons of professors there who I just wanted to. You know, I wanted to. At one point, I thought I wanted to go into academics because, you know, that relationship between the teacher and the class and the. The pursuit of knowledge. I've always been insatiably curious. And of course, in college, that gets satiated every day as you learn more and more about the world and how it works and how it got to where it is. And, you know, I have to say that I probably.
I was curious and committed to learning the science. I loved history and literature and drama.
Those were my first loves. Really? Is that part of the educational experience? I. I participated in drama. I was in several plays, you know, in addition to the. You know, this is, again, small school. You get to do lots of different things.
[00:16:34] Speaker A: Yeah.
So do you still feel like you have a strong connection to literature? Are you, like, an avid reader? Is this, like, a big part of your life?
[00:16:40] Speaker B: Yeah, it is. I love to read, and a lot of my reading now I do by listening because I. I do it while I'm walking.
So you know, audible app or whatever else. I'm also a big fan of podcasts. I, you know, I. I take my own medicine, if you will.
[00:16:57] Speaker A: Then, boy, do I have a show for you.
[00:17:01] Speaker B: So, yes, that's. That. That insatiable curiosity, always wanting to know more. And. And I've always been fascinated by how one can take ideas from separate spheres and. And create or understand the connections between them and how they might apply across a specialty or a discipline. That's always been a fascination for me, sort of that synthetic creativity, if you will, of bringing ideas together. And I have to tell you, Alden, I, you know, the podcast really is a very selfish pursuit because I've always enjoyed having deep conversations with people about purpose and meaning and about ideas and, and how we can be better and how we can make ourselves better, how we can make society better. All of those things have always really fascinated me. And when I interview a guest, I'm quite literally trying to unpack what they know and add it to that mix and. And maybe take it a step further in my own learning. So really a selfish pursuit.
[00:18:06] Speaker A: And what was the experience of med school like for you?
[00:18:09] Speaker B: It would be hard for me to say that I enjoyed the first two years because I did not.
It was a lot of rote memorization, and again, I was hard of hearing. So I would go to class and I couldn't hear the professor. But you were kind of.
They frowned upon missing too many of those. And so it was really sort of frustrating because I would rather be studying, you know, but highly dependent on those. Those folks who take great class notes and sell them, you know.
[00:18:44] Speaker A: So were you still feeling, like, very dedicated? Were you still feeling. Or was it just like, this is what I'm doing and I'm just going to get through it?
[00:18:50] Speaker B: Yeah, at that point, it was the latter. This is what I'm doing. I'm going to be a physician, you know, come hell or high water, and I will get through this. And I did okay. My first two years. I wasn't at the performance levels that I had been in college, but I did fine.
I didn't excel until I got into the real clinical practice. In the last two years of medical school, when you start seeing patients, you know, I say that lightly because medical students are always sent off to go and get histories and physicals and, you know, grilled about answers to questions and so forth. But I loved the interaction with people. I mean, that. That fed me and got me through the second. The second two years. And, you know, there were some professors There that I absolutely loved, a gentleman named Alan Bowen.
And he was just such a fun guy to hang out with. And we'd do rounds, and then, you know, we'd all go have lunch together as a team. And he was funny and sarcastic and wry. And he was the one who said, you know, you need to go to Parkland. And, you know, what the heck is Parkland? I never heard of that. And. But Parkland is the University of Texas Southwestern, a very storied program.
At that time, Parkland Hospital was the name of the county hospital in Dallas, Texas.
For those that know Atlanta, it was like Grady or like, in many ways, like Cook County Hospital in Chicago.
It's where you see anything and everything. It's where the least enabled members of society, you know, the knife and gun club, alcoholics. I can't remember even today the other programs that I applied to because Alan Bowen had convinced me. So I was ecstatic when I got in.
[00:20:44] Speaker A: Incredible.
[00:20:45] Speaker B: And, you know, at that time, you know, it was still. There were no work restrictions. They could work you as hard as they wish to, and they did.
[00:20:53] Speaker A: Let's fast forward just a little bit, and I'll ask you maybe like more of a softball question, kind of an easy one. What do you think are some of the biggest problems in healthcare today?
[00:21:03] Speaker B: Oh, my goodness.
How long a list do we need to make? I think there are fundamental problems that drive a lot of the other issues.
And we hear a lot about the reimbursement system, about how fee for service incentivizes more and more. And what that means is that. And you know this, if you've ever been to the doctor, everything they do comes with a bill.
So there are E M codes, evaluation and management codes. That's what they bill you. If they just talk to you and try to discover what's going on, you know, sort of that diagnostic sleuthing, if you will. Then you get billed for the labs, and you get billed for the X rays and get billed for the EKGs. But what a lot of people don't know is that if a doctor recommends an ekg, sometimes they're the ones reading them, too, and they get paid for reading that ekg.
Now, that's not always true of every test, but there are, you know, pulmonary function tests for pulmonologists. If they've got a PFT pulmonary function equipment in their office, then very often they're billing you not only for the professional component, but for the lab, if you will.
And so there's. It's not that doctors are bad People, it's just at the margin, the tendency is to do more.
[00:22:29] Speaker A: Right.
[00:22:29] Speaker B: That, I think is problematic, although there are folks that believe that that's not the fundamental problem. And, and that the fundamental problem is that there is a shortage of physicians and providers of all types now.
And that's the basic economics. Right. If it's a scarce resource, it's going to be more expensive.
[00:22:49] Speaker A: Interesting. Yeah, interesting.
[00:22:52] Speaker B: I'd never thought of it that way until Scott Becker made that comment to me.
[00:22:57] Speaker A: Though it does seem, it's intuitive to me that like all else aside, that if a doctor has the option of doing something not even unethical, but just of, you know, leaning one way or the other, if there's an incentive for them to want to do it financially, it seems obvious, I think, that a lot of the times there's a resistance to think about these issues at a systemic level. It's the sort of thing that bears out in the data. It's like something as simple as, like, you know, you put the fruit on the top shelf and the candy on the bottom shelf, you eat more fruit. If you put the candy on the top shelf and the fruit on the bottom shelf, you eat more candy.
[00:23:39] Speaker B: Yeah, yeah. And that's a good analogy. And I'm, I'm convinced that it's not a single issue.
[00:23:47] Speaker A: Of course.
[00:23:48] Speaker B: Ian McGillcrest wrote a book called the Master and His Emissary. And the whole point of the book is that as we have evolved, we have moved more and more towards left brain function rather than right brain function. And the difference is the left brain is highly analytical. It, you know, it's how you manipulate the world. It focuses on one issue at a time, usually sequentially, and, you know, knocks them out. Whereas the right brain has been tasked more with context, relationship, big picture holism.
And the idea is that because the left brain controls language, it is gradually sort of taken over and I think ultimately devalued those things that the right brain for which the right brain is the steward. So as an example of that, you know, I, I, I've talked about this before.
Pay for performance is a very left brain thing. It's like, oh, it's obvious. If you want people to behave in a certain way, you pay them to behave in a certain way and that's what they'll do.
Now, that's different from fee for service, which is an at the margin influence.
[00:25:06] Speaker A: Yes.
[00:25:07] Speaker B: This is trying to adjust behavior by rewarding things that physicians do.
Don Berwick, who was CMS administrator for a while and the Institute for Health Care Improvement wrote a whole piece on this, gosh, in the 90s about the toxicity of pay for performance. And his point was that incentivizing physicians to behave in certain ways around a limited number of metrics devalues what real health care is about. It devalues the context, the, you know, the nuance, the relationship, the meaning, the purpose. We become a set of numbers in terms of our value to the system instead of human beings.
[00:25:50] Speaker A: The other thing that it brings to mind is the standardized testing in schools. Well, you know, and how, you know, there's. At a certain point, you know, it's all well and good to say you want to measure performance, but who's measuring it and by what metrics? And what are the consequences for not performing right? Does this sort of take more money out of places that don't have the resources to achieve the same levels of performance as places that are either more affluent or just more well equipped for certain tasks?
[00:26:20] Speaker B: You're exactly right. That is, that is the perfect analogy. But it's more than that in that being a physician is a complex task. And every time patients have been asked, they value caring over curing. They know that we can't cure everything. They understand that they're, you know, they all die. As dad said, number one, cause of death is being born. When we measure physician performance by a set of metrics, what we've said is really don't care how you get there, make sure you hit these targets, or your income's going to suffer. Yeah. And so it puts an excess focus on a limited number of things independent of context.
And, you know, I think that's the source of what's being called moral injury, or a lot of what's being called moral injury. In other words, physicians being expected to do things that are not why they got into this. You know, it's like, yeah, I'll hit that metric, but I really would like to spend time with my patients because that's what I wanted to do. I wanted to have a relationship with them. And then the, the, the, the downstream effect of that is, you know, you can't evaluate a patient in 10 minutes. I'm sorry, it's not possible.
And if you lose the time, you lose the relationship, you lose the trust, then it's all just throwing numbers at things and, and treating numbers does very little to advance humanity, in my opinion.
You know, what's the point of living longer if you're miserable? Is one question.
[00:27:54] Speaker A: I, I fully see where you're coming from there. I mean, I can just Speak to my experience living in New York now, which is obviously in New York, you know, I need to go to even see my primary care doc or urgent care or anything like that. A lot of the times I don't even get asked my name. You know, it's something as simple as walking in what's going on? Okay, here's what it probably is. Here's your prescription. Bye. You know, and it's like I don't feel like I adequately had time to explain everything that was going on. And I certainly don't feel like, you know, and that's partially just New York. Right. But there's another level to which it's
[00:28:26] Speaker B: like, I'm not against the advances in data and the advances in technology. They saved my life. Okay, I highly value those.
But we have devalued the, the parts of it that make it really meaningful. And that's the time in a therapeutic relationship to develop insight, to develop trust.
If you want patients to engage, as we all talk about these days, how do we encourage engagement? How about a relationship of trust where you don't want to disappoint your doctor because you like them, you respect what they have to say, you know, that they care about you and we don't allow enough time for that.
[00:29:11] Speaker A: That being the case, it's something that comes up a lot on the show about the sort of hyper specialization and siloing of different specializations apart from each other.
What of the solutions that you've become aware of to that kind of issue? Which one of those clicks the most with you? Which one of them do you find the most interesting or inspiring?
[00:29:34] Speaker B: First of all, I'm going to talk about tools that can support human beings in doing. I'm not talking about replacement, I want to make that clear.
But I think clinical decision support and a specific kind of clinical decision support. When I say that that's a term that we use all the time in healthcare. And what it means is that you've got guidelines that either either from professional societies or have been developed locally based on best evidence and, and that, you know, if this, then this is how you should proceed. How do you manage a heart failure, for example? And there are a set of specific guidelines based on all of the parameters that you can measure around heart failure about exactly how you should proceed in managing that.
The problem is, is that that's not historically how medicine has been done. Historically we've kept thing in our head and, and said, dear patient, I can craft for you the best customized plan because I'm a Smart guy. And I studied all of these things.
That doesn't cut it anymore. It's become far too complex for the human mind, unaided, to be able to make smart decisions down the line. And so I think the opportunity to implement clinical decision support and the best method that I've ever seen goes back to continuous quality improvement. And Deming, who was the guy who taught the Japanese how to kick our butts at making cars interesting, it's somewhat complicated and cumbersome to make it happen, but the best I've seen is when you take key processes in the hospital and then you get all of the experts together and you come up with a standard way based on the evidence to manage that set of circumstances, then you become hyper focused on collecting information on how it works, right? So that you can continuously improve that model over time.
The folks who got it right, about as much or more so than any other, had been at Intermountain Health and you know, they were touted by Obama as one of the most efficient. And if everybody did it as well as they did, we'd only pay X for health care.
But their, their secret sauce really was this whole process of developing expected clinical practices for key processes and breaking it down to, okay, what happens next, who does it, what do you do if then. And then each time somebody deviates from that. And by the way, you must deviate from that practice. No protocol perfectly fits any patient. But when you do, you have to ask the question, does that mean the protocol is wrong and we need to amend it? Does that mean the doc is wrong, we need to educate him, or is this just a customization necessary? That protocol doesn't need to change, but it was appropriate in this patient.
[00:32:23] Speaker A: Interesting.
[00:32:24] Speaker B: It's really reliability theory that's at work here. In other words, how reliable are your processes if your inputs are A and B, how often do you get what you want, which is C versus something else? And the way to do that is to standardize and build in evidence based processes.
You know, one of the tricks that is important is getting the folks that are actually delivering the care to agree.
So having that forum where you say, what do you think? You know, should we do this? Should we do that?
I learned that lesson very well when we were doing the same process for sepsis at Banner, and I had one doc who kept saying, I don't think we need to, you know, to do that steroid part. I don't think we need to do that steroid. I think it was the steroids that he was talking about. Bob Raschke another one of my mentors.
And, you know, I was thinking, bob, so, you know, more than the, you know, international consensus on sepsis, he was going, no, I'm not saying that. I'm just saying I'm uncomfortable with it. I don't think the evidence supports it. And it wasn't a year. And so finally I said, okay, we won't do that part. It was probably not a year later that it was withdrawn as part of the international consensus, because fact was, the evidence wasn't there.
[00:33:44] Speaker A: It happens more often than I think people realize. I think that there is this thing. I think people have this attraction to the idea that it's like, oh, this is what the science says, or follow the science. And while that's obviously true, I think that the science is not a monolith.
[00:34:02] Speaker B: Yes.
[00:34:03] Speaker A: The science is an active pursuit. It is something that is evolving over time. And frankly, some of the data is provided either by bad actors or. Or bad studies. You know, you can prove that with 90% accuracy that this does X. If your sample size is 10 people, 9 people happen to respond, you know, it's you. I think that there has to be a level of curiosity into what are these studies specifically. I think that having a little bit of literacy around what a good study actually is makes a big difference in being able to make those kinds of judgment calls.
[00:34:38] Speaker B: Absolutely critical. And there is so little understanding, even among physicians of the real nuances of interpreting clinical studies. And as we've gotten more and more studies that are funded by drug companies because the National Institutes of Health has reduced funding significantly, there are biases built in. Unavoidably, occasionally you have outright fraud, but most of the time it's human beings being human beings, incentives that are not in the best interest of the patient, necessarily.
[00:35:12] Speaker A: I mean, it comes down to stuff that is not specific to health care either. Like, there is much more. You're much more likely to get published for a new finding than a confirmation or rejection of an older finding. Right?
[00:35:26] Speaker B: Yeah.
[00:35:26] Speaker A: So the incentive is to publish something new more than to publish something correct or useful.
[00:35:32] Speaker B: Yeah.
[00:35:33] Speaker A: And so again, at the individual level, maybe company X or person X is not trying to actively commit fraud, but at the margins, you know, if you're trying to decide, should I publish this? It's like, well, the more papers that I have published, the more, you know, the better it is for my career and thus my family and my children. You know, like, does it even have to be coming from a place of greed? It can be coming from a place of Like, I'm just trying to want
[00:35:58] Speaker B: to keep my job, you know, truly.
[00:36:01] Speaker A: And so you having to, you know, if you're on the fence, maybe you do make the call of like, well, it's a little spurious. It's maybe not the most concrete data I've ever had, but it is interesting and this publication is interested in it, so. And then of course the news sensationalizes it and you've got on the front page aspirin cures cancer or whatever it is, and it's like, well, and there
[00:36:24] Speaker B: are always questions about association versus causation. Of course, things that are associated don't necessarily mean that one causes the other. Right.
[00:36:33] Speaker A: The example that comes to mind is how left handedness has reduced drastically alongside the proliferance of smartphones. Right. And so it's like, do smartphones make people left handed?
[00:36:44] Speaker B: You know, there are lots of, you asked a while ago, what's wrong with health care? Well, we could talk about challenges with the revolving door at the FDA where, you know, somebody that's been at the FDA has a good shot at being an industry and being a well paid consultant once they're done at the fda. Yeah, you know, the FDA is a kind of low paid, thankless job. And so it's not unusual for people to say, hey, I'll do this low paid, thankless job, but I need to look for something, you know, that'll do for me in the future. But then it starts to bend, intention, etc.
So it's not necessarily malicious people. It's a system that has built in incentives that don't necessarily serve us anymore is the way I would think about it. And I want to reemphasize that. You know, I spend a lot of my time criticizing some of the things that we do in health care, but I'm not criticizing the people. It was Deming, in fact, that showed us that the vast majority of problems and errors that we see are not due to people. They're due to systems that are misaligned, malfunctioning or not optimized. You know, they're clearly system problems. And it's not the individual worker, if you will, that is commonly responsible. And I think it's to the tune of like 93, 94% are system issues.
[00:38:01] Speaker A: Do you know about the fundamental attribution error? Have you heard that described as such?
The example that comes to mind is idiot drivers, right? Like people on the road are what a bunch of morons. You know, someone cuts you off and you're like, that guy is A jerk. And probably with a little bit more stern language than that.
The experience of being behind the wheel of a car, regardless of it being something that we take for granted as being part of our lives, it is, at a physical level, a very stressful thing. You're moving very quickly. You're responsible for your own life and the lives of all the other people with you. And everyone has at least some sort of awareness that it's very dangerous, regardless of whether they are paying attention or not. And a lot of people don't. At a certain point, you have to address like, okay, is there something we can do about the system of, I guess in this example, transit infrastructure that might lead to fewer car accidents, rather than saying, oh, people are idiots and just accepting that car accidents happen, Maybe you can change something at an infrastructural level that doesn't presume that thousands, hundreds of thousands of individuals will spontaneously start making different decisions with no other input whatsoever.
[00:39:19] Speaker B: Yeah, we've seen this, We've seen evidence of this, that cars have gotten a lot safer over time. I mean, from, from the time when I started driving. Gosh, you're far more likely to survive an accident today in an automobile. Why? Because we, it's the system that changed. It's airbags, it's, you know, it's the, the crumple zones.
You know, sometimes it's just easier, and I think it's almost human nature to want to blame somebody when something happens. We want to point a finger because, you know, in part we want it to go away so that, you know, we don't have to, to think about how arduous it's going to be to change all this.
[00:39:56] Speaker A: Right.
[00:39:57] Speaker B: It's a, a knee jerk reaction to blame the person when in fact, if you look at the system in which they're working, you could substitute many persons, if you will, into that situation and you get the same result.
[00:40:09] Speaker A: I've experienced this in my life. You know, you put me in one context, as, you know, I was also an unruly youth.
[00:40:17] Speaker B: It's only fair, I think, you know, that you were.
[00:40:19] Speaker A: But go ahead, turn about's fair play.
[00:40:21] Speaker B: Yep.
[00:40:22] Speaker A: You know, I behaved in a way that was very unethical. I did not treat people necessarily with respect or compassion. And you take the same person. You know, just full disclosure, I'm comfortable saying this. I've said this online before. I went to inpatient rehab when I was 17. And overnight you change the context from being around drug addicts to being in recovery.
I was a different person. Yes, 24 hours. And by the way, you can thank this man for making that happen.
[00:40:54] Speaker B: I want to take credit for all the good stuff, but none of the bad, if that's okay.
[00:40:57] Speaker A: Deal.
So it's obvious to me that the same person in two different contexts is two different people.
[00:41:05] Speaker B: No, I think that's absolutely true. And one of the. There's a lot of hype around AI right now and what AI can do for healthcare. And I think long term, I think it's absolutely true that AI will be a revolutionary tool for health care. I don't know that it's going to happen as quickly as we want it to, but I think it will happen.
I'm thinking about it as a tool, not as a replacement. And my hope is that it can help us cut through some of the complexity. I mean, one of the reasons, and I've told Brent James doesn't believe this, but one of the things that I believe about his effectiveness at Intermountain Healthcare is because he's Brent James. You know, he is a great leader who knows how to motivate people. He knows how to teach people. He knows how to design the solutions that will improve the system.
And unless we can clone him, which may be in our future, who knows, you know, it's, it's hard to do. You know, he staffed, for example, he staffed Intermountain Health with a lot of statisticians and they're very knowledgeable about these quality improvement projects and, you know, statistical control charts, etc. So that it really is a learning organization. Each time they implement a process, they're continuously learning how to improve it.
That's not easy and it takes significant motivation and leadership.
I wonder whether AI under the right leadership might not be able to cut through some of that complexity and make it easier for the average Joe like me to get the kinds of results that a Brent James gets. If I have that statistical, you know, chat GPT on my shoulder, if you
[00:42:54] Speaker A: will, I, I've used chat GPT to kind of help me come up with release plans for music or try to help me do this. And so I've done some experiments with like, okay, what would be the two month goals? Like set up, what should I do two months before the release, one month before the release? What are all the boxes in determining that big picture pattern? In my experience, it's excellent. It's at least as good as people that have offered to be a consultant for me for thousands of dollars a month. And those are the roles in which AI right now is already poised to be very, very effective is in recreating those patterns that are effective in a big picture way.
[00:43:32] Speaker B: I think that's an important, in terms of what it's useful for today, particularly large language models. Now there are specialty models that can get very good at, for example, computer vision for looking at dermatologic lesions, lesions on the skin or looking at X rays and at least prioritizing them for reading by human beings.
And so there are specialized models that can be very good at specific tasks, but generally artificial intelligence. I think your site is, is very accurate and very clear that you have to be careful.
One of the stories that Dr. James tells is that somebody at Stanford was using a, an AI model, a general AI model for diagnostic support, in other words, trying to figure out what somebody has. And it came up with a bogus diagnosis, one that doesn't even exist.
And when it was directly challenged, it doubled down on it and said no. And here's a reference that it made up, you know, so wow, real confabulation. And here's the interesting, you know, how I like to play with ideas. And I started thinking, well, you know, we know from, from split brain studies and from patients who have had strokes that if you knock out the right side, the left side will make stuff up. You know, for example, in a split brain study, you talk to the right side of the brain, which does not have language, right? So you talk to the right side of the brain and say, pick up a key. And so it, the right side of the brain controls left hand, it picks up a key and then you ask the left brain, you know, what is that? And you know, if, you know, you hand it to the other hand, it'll say it's a key. And then if you ask it, well, why did you pick that up? It will make something up and double down on that.
And so it's just fascinating to me that not only is the left brain, which is manipulative and you know, and not in a bad way, but manipulate the pick something up, you want to know exactly where it is, etc. And science is important and data is important and statistics are important, but for some reason that side of the brain cannot be wrong.
[00:45:51] Speaker A: Let's switch gears here for just a second. I want to talk about some of the work you're doing in the conversations. You're starting around flipping the prior authorization model, right? Oh yeah, because that's something that it seems like you're taking big steps on right now. And I want to understand it a little better. I want people I know you just had a big conference that went very well. I just want to, I wouldn't mind
[00:46:09] Speaker B: if you spoke a little bit on that prior authorization. Anybody that's ever dealt with the health care system in depth as a physician, as a patient, you know what I'm talking about. And, but what it is, is there are certain things that are very expensive and that because of our incentive structure and fee for service system can be overutilized.
You know, not everybody with a headache needs a CT scan of the brain, for example, not everybody with acute back pain needs a CT or an MRI of their lumbar spine.
And so what insurance companies have done, and this includes the government, you know, Medicare and Medicaid is they've said, look, if you want to do this particular study or you want to do this particular procedure, you have to get prior authorization by the insurance company because unless it is, quote, medically necessary, we're not going to pay for it. Now they're not telling you you can't have it, which is what they always fall back on when they say, well, you're practicing medicine without a license. No, we're not. We're just telling you that by contract with us, we're not going to pay for it. Now health care has gotten so expensive that that is by default essentially saying, you know, for most people you can't get it right. But oftentimes it is justified to say, no, you shouldn't get a CT scan for somebody who just showed up with their, you know, with a headache that's typical of all of their headaches, etc.
Or you don't need an EKG every three weeks and somebody.
And then there's, there's this concept called over utilization or over diagnosis that is a real thing in healthcare.
And it's in part because of the fee for service system, in part because we, we hate to miss stuff and so we throw the book at everything. The problem is is that that's not benign. It has financial consequences and it can also also have actual patient harm consequences.
Prior authorization is sort of a mother may I manual process where you know, the doctor in typically the way it works is the doctor in his practice writes for an MRI of the spine and then he walks away and goes to the next patient and his staff then says, okay, I got to look this up. Who's their insurance coverage is this? Is prior authorization required? Oh yeah, it is. And so they fill out a form and they submit that to the insurance company.
And then the insurance company has physicians that review that information and say yeah or no.
And it takes weeks for this to happen sometimes. And it at a minimum, because it's manual, it takes days.
And that can end up delaying needed care for patients. It certainly interrupts what it's trying to interrupt, which is unnecessary testing. But there are lots of downstream consequences because the way it happens. My question is, isn't this just clinical decision support? Isn't this just.
The doctor at the point of care needs to know, number one, is this what I should be doing? And number two, does this person's contract with the insurance company, does it meet all the criteria I need for them to pay for it because of the delayed response? It pits the physician and the or pits the patient against the physician and the insurance company.
[00:49:37] Speaker A: It's almost like having a telephone operator that is physically connecting the cables. When it's like it is, we could just systematize the phone call.
[00:49:46] Speaker B: Exactly. And so I don't think prior authorization honestly should exist. I think it ought to be clinical decision support at the point of care, at the time the physician is seeing the patient.
Now, what they'll learn from that in good systems is, number one, is this what I should be doing? Well, if that's the case, but you still, and you'll know right then and there that the insurance company is approving it or they're saying, nope, we're not going to approve it until it's reviewed and it'll tell you why that's the ideal system. And then I know right then and there, but my protocol says that this is. And here's the data supporting that. And so I can have that argument in real time with the insurance company instead of waiting two weeks while the patient languishes or shows up for the test and then is told, no, we're not doing it because it's not being paid for.
I don't know why we need to do it that way anymore. I think it's a. I think it's a flawed system and that we can fix the system with the technology we had today. As I said, some of this can be done on checklist. And the example that I can give you for that is again from Intermountain Health. They've done a lot of work on this.
There were a lot of excess cardiac procedures being done. Brilliant technologies. It's life saving. But those same strategies can be abused.
And Intermountain Health had been paying attention to this and they were in the bottom quartile. In other words, you know, 75% of the country was using these procedures more often than Intermountain Health and Intermountain Health had good evidence that they were doing it the right way, but they were using an old prior Auth system. And one of their docs basically said, hey, I can put this on a single sheet of paper, and if you check a box saying that this patient has X, then you're allowed to do Y.
Let's call that prior auth. And they sold it to the insurance company. And the insurance company said, yeah, okay, that works. And ultimately what they found out was that they reduced it even further by an additional 25% just by having a manual checklist.
And so why are we doing this antiquated, complex, convoluted, human resources intensive process that irritates everybody in the system when what we really need is clinical decision support? That's my question.
[00:52:08] Speaker A: When it comes to prior authorization, what does that clinical decision support actually look like? Nuts and bolts. What do you envision that being?
[00:52:15] Speaker B: Yeah, so let me give you two examples. One is old school. Patient comes in, doctor evaluates him and says, yeah, what you need is a knee replacement. We're going to schedule you for that next Thursday.
And then the wheels start turning. It's like, oh, a knee replacement, that's prior auth. That's expensive. It's in a process that's often used unnecessarily. So we're going to have to review that. And so it goes off into the machinations of the insurance company for review and back and, you know, et cetera.
What I would like and, and what the. The reason that it gets denied, let's say, is because they haven't had physical therapy for six weeks or whatever the requirement is. There's a reason that that requirement is there.
It shouldn't be universal, but there's a reason it's there because some people get better and never need surgery.
And so wouldn't it be important to try that first?
So the way it works today is the doctor doesn't even know sometimes that it's a requirement. And so they just write the order and then they find out later, oh, no, you can't do this. Because the patient. And then the doctor, you know, cries foul and says the insurance company is practicing medicine without a license. And the patient gets mad at the insurance company and the doctor because they were told they were going to get surgery. Their son's coming in from out of town to take care of them afterwards, you know, and he's, he's taken off work.
And it's just this whole morass that's created. And here's how I envision it working.
The patient comes in, the doctor has clinical decision support built into his ordering system. So when he orders a knee surgery or whatever it is, an alert pops up and says, we've looked at the data. This large language model has looked at, you know, text data in addition to the, the hard data that you can easily pull out. And we can't see any evidence that this patient has had physical therapy for six weeks while the patient's still sitting there.
Not, you know, you find out a week later, but while the patient's still sitting there. And so the doctor can scratch his head and say, and by the way, the evidence, you can click through and look at the evidence for why it's there. And the doctor can look at that and then say to himself, okay, I think we should do physical therapy. Or perhaps he knows a reason why that's not appropriate in this particular patient. And they can have that discussion right then and there instead of waiting for two weeks and setting everybody's expectation. Or maybe he didn't know that evidence, but as he's ordering it, it comes up. And so his discussion with the patient is, you know what, on second thought, I think we ought to do this first.
That's clinical decision support, the way it should work, in my opinion.
[00:54:59] Speaker A: Awesome. Yeah, I love all of that. So I'm curious for the, for the people that are listening right now, what are things that you feel like they can do to get involved in this conversation?
[00:55:09] Speaker B: One of the things that is, is a little bit troubling is that, you know, healthcare literacy, you know, some quotes have been around 12%, you know, of, of the lay population understanding what the heck is going on in healthcare. I understand that what the a mechanic is doing to my automobile. Right. I mean, I'm not an expert in that. Health care has always been a little bit different because it is unlimited, unbridled demand. Right?
[00:55:40] Speaker A: Yes.
[00:55:40] Speaker B: And are no limits on cost right now. They can continue to spiral up and up and up until, you know, we hit a wall or have some sort of financial disaster, which we're not far from. And people have been saying that for a long time, but it ain't getting better. The first thing you can do is educate yourself.
And how do you do that? Well, start to pay attention to folks like Eric Bricker, who has a blurb that comes out periodically on LinkedIn where he just goes through, how does an insurance company work? How does a PBM work? You know, how do physician practices work? And it's just incredibly informative and Healthcare is one of those things that, you know, if we're lucky enough to live a long life, we're going to encounter it in one form or another, or the likelihood is that we're going to encounter it in one form or another. And so educating ourselves on one of the most important things about our existence seems to me to be a good thing to do. And so, you know, start to listen to podcasts or read books like, you know, Robert Pearl has a book out about, you know, why, gosh, what's the name of it? It's why we think we're getting excellent care and why we're usually not, or something like that.
And, you know, it highlights the problems in American health care. And what you can do about it is put pressure on legislature or legislatures to address it, cry foul when you see a foul. And we collectively as a society need to determine how we're going to manage the care of our nation because we're getting older, we're getting sicker, and there have to be some steps put in place to right the ship, if you will, or health care will. You know, I forget who described it as the leech that's sucking the blood out of the entire system, but it truly has been 20% of GDP. Now, what should it be? I'm not sure, but it shouldn't be any more than is necessary and it shouldn't be exorbitantly more that is necessary to ensure a good health span, which is how long you live a healthy life without major disability and lifespan, which is how long you live, period.
Marty Macary, maybe it's Makary. Marty Macary has a grassroots organization that's trying to address some of these issues. So the first thing is educate yourselves and you don't have to have an in depth understanding. A lot of these concepts are not difficult to grasp.
There's a lot of obfuscation in health care. There's no price transparency that shouldn't exist. And we're starting to make some progress towards that. There are transparency rules that have come out recently, but special interest groups resist in areas that directly impact their pocketbooks like you would expect them to.
[00:58:42] Speaker A: Well, there's also, I think, a difference between transparency and intelligibility.
For example, my insurance plan, my health insurance plan, I can't claim that it's not transparent. Right. Like strictly speaking, the terms of the contract that I have signed are in that packet. But I think I, even as a person who has some tangible connection to this space, I still have trouble understanding a lot of. Because you said there's obfuscation, intentionally or otherwise, that takes place in there. So I think that sometimes transparency is not enough. It has to be intelligible. It has to be made approachable by the common person. And so you could say, okay, well, healthcare literacy is down. You could also, you know, healthcare complexity is up.
[00:59:27] Speaker B: Yes.
[00:59:28] Speaker A: And there's no real incentive to make that complexity available to the public, at least not in any kind of approachable way.
[00:59:36] Speaker B: Yep. I absolutely agree with you. And those are all things. I mean, the whole point of the Groves Connection is to try and start digging into this, some of this stuff and get a variety of perspectives and understand. Again, I'm not trying to say that companies are bad or people are bad. What's bad is the system.
And correcting that is going to take some effort, but it's going to take grassroots effort, I think, because it becomes so entrenched politically that it's really hard to dislodge. And so unless there's enough public outcry, it will continue.
[01:00:16] Speaker A: I think we explored some interesting ideas today and I would love to be able to dive more into that again. So hopefully we can do this again.
[01:00:22] Speaker B: And Alden, I want to say one thing to you that I don't say to every guest. Perhaps I should, but I love you.
[01:00:28] Speaker A: I love you back.
This was a delight. Well, thank you so much everybody for tuning in. I'm going to do my little editor producer spiel for a second. If you haven't already, subscribe to our podcast on whatever medium you're listening to it on right now. We are independently run. It's just us. You have seen the faces of the entire production team during this interview, so it helps us a lot if you leave us a review on Apple podcasts. It helps us a lot if you comment. To boost engagement, subscribe to our YouTube channel where the actual video interviews go up. It's really makes more of a difference than I think people realize. Do you have any parting words? Any anything you want to leave the listeners with?
[01:01:07] Speaker B: No. Thanks for listening and we'll see you next time.
[01:01:10] Speaker A: Bye bye.
[01:01:11] Speaker B: Bye bye.
You've been listening to the Groves Connection, your connection to the inside story on health care, featuring in depth interviews with those who know. You can find us on Apple Podcasts, Spotify and anywhere else you get your podcasts. If you like what you hear, give us a five star review to keep the connection going and hit the subscribe button to be sure you never miss a beat. The Groves Connection is produced by Dr. Robert Groves original Music Editing and Creative direction provided by Alden Groves Production Support Content guidance courtesy of Janae Sharp and Elizabeth Barrett thank you for listening.
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