SPEAKER_03 0:00

Welcome back to another episode of Vitals and Values. We have our second Dr. Todd in a matter of a few weeks. I will not say which of these Dr. Todd's I enjoy more because they came from the same source, too, which is hysterical. And Dr. Todd Otten, I wanted to first welcome you to the show. I appreciate you being on here. Kind of walk me through your backstory because I find your backstory inside of medicine very similar to Lara here, very similar to a lot of people, and taking bold shifts. So walk me through your backstory. I'd love to hear it.

SPEAKER_04 0:34

Sure. I'll give you the short version so I don't bore everybody here. Uh and I won't read my C V. Uh so I finished med school in 2002. So I've been practicing for a while. I was in the U.S. Navy. I thought I wanted to be a trauma surgeon when I got out of school. And I had the pleasure of uh doing my interim year before the 80-hour work restrictions. So I got the full effect of what it was like to be Q2. Yes. Oh joys. Not how I would describe it potentially. Um but, anyways, I and I realized it was a little, I mean, at times it was almost sadistic, the training. And I'm like, what did I get myself into? And so fortunately I was in the U.S. Navy, as I said, I pivoted. I trained as a flight surgeon, which is a total misnomer. It's primary care. And I really yeah. I'm not, I wasn't doing appendectomies on a plane or anything like that. I mean, I was essentially the primary care physician for about 500 people in the squadron, pilots, navigators, etc. And I could I could explain more about that. But uh I so I learned to love primary care. And I finished my time in the service, came out in my residency, went to a critical access hospital, was in the feed for service world for 13 years, did all the things, leadership, what have you. 2019 I went through, in retrospect, classic, pretty horrendous burnout. Like I I have always loved my job seeing patients, and I hated it. I mean, I'd be in the backyard in tears, just miserable, not wanting to go to work. And that kind of set the stage. That really started to, I started to ask a lot of questions, like, what am I doing? Like, is this where I should be? And then we got absorbed by a larger system. I say they were a toxic healthcare system, which they were, um, and poor decision after poor decision was coming down the pipeline. And in 2022, I had taken over clinic and it was going very well. And they made a decision essentially to move me back to where I got burned out with no warning. And I basically gave them the middle finger. Um, and that led me on this amazing networking advocacy journey. Fast forward a little bit, I've had some interesting consulting roles over the past couple years, and currently I'm doing direct primary care in addition to advocacy work and obviously involved with training the documentary Suck It Up Buttercup. So hopefully that gives you a little bit of background.

SPEAKER_03 2:50

Can you give me the the little more detailed story behind your previous uh employer on the sequence of events? Because I find that story fantastic. You'll find it if if you're allowed to speak about it.

SPEAKER_04 3:02

Oh, yeah, I wrote a I wrote a book about it. Um so it's it's out in the public space, and I've talked about it a bit. So, you know, it was when I came back from burnout, it took me really a couple years to kind of recover from that and to kind of get in a place where things were going well. And I was I was in a clinic where I was managing or supervising rather three nurse practitioners, and we were busy and things were going well. And there would be these decisions about like, oh, you need to move this hour here, or you know, Friday afternoon can't be an administrative time for the staff, even though we were open till like 8 p.m. Monday through Thursday. Like we had to be open till eight o'clock on Friday. And I was like, this is ridiculous. Like calls are getting answered, patients are getting taken care of. You know, who cares if not everyone is seeing patients all at the same time when we're getting the job done? So it was stuff like that. And I would I would advocate for retention, uh, well-being from my colleagues, and and so on and so forth. And it was like it fell on deaf ears. Um, the the where the crap hit the fan, if you will, I went into a meeting on logistics. And I walked into the meeting with a coffee cup that said, be careful or you will end up in my novel, and set it on the desk in front of me. And the VP's like, is that a warning? And I'm like, Well, I guess it depends on how this meeting goes. The meeting went like shit, excuse my language. You're good. I resigned the next morning. I'd been there almost 13 years at that point. And that led to a whole domino effect of people leaving the system. We had 15 people in the staff uh on staff at that office. Two NPs left the system, I left the system, and then um six ancillary staff left for four months.

SPEAKER_00 4:44

And now when you say burnout, what what would you define that as? And was that a slow process over time?

SPEAKER_04 4:52

Uh yeah, probably slower than I in retrospect, it was kind of I mean like, you know, um lack of empathy, angry, frustrated, lack of compassion, lack of fulfillment, uh sense lack of sense of worth, you know, all those things were going on. I mean, there was and the problem with it is my patients were not getting my best at all. You know? So I mean, if you hit a uh checklist, I probably hit everything all the box. Yeah.

SPEAKER_00 5:20

Yeah, I think did you say something about when I got through burnout or recovered from it or something like that? And what does that mean and how did you do that?

SPEAKER_04 5:31

Uh yeah, great question. So um therapy was part of it. Um very helpful. Starting to process some of the wounds that I had had, um, and not even really understanding how much trauma I had endured in my life at that point, but starting to dive into that a little bit. Writing was very cathartic for me, writing the book. Um and then I I think being in the clinic where I was teaching was also helpful. And so I my my volume at the time was maybe 20, 25 patients a day. And then I had kind of an open door policy and would teach CNPs, and I think that was healing for me as well. So I I say recover, I I mean I think it's kind of a continuum. Sure. Yeah.

SPEAKER_00 6:12

No, and I met you through Todd Chassis, who was on before, and then you were in the midst of and still are, I believe, on this whole uh documentary about physician burnout, correct? Is that what you describe it as?

SPEAKER_04 6:27

I it's I it's broader strokes than that. Yes, yes. And I'm happy to honestly elaborate.

SPEAKER_03 6:33

Suck it up buttercup, this whole documentary, the sequence of it. I've been able to see a few iterate iterations because the the fascinating part from my point of view, seeing the doc in its uh just like we've dealt with ours, but there's so much to unpack in obesity to think you're gonna put it in one episode, one type of episodic deal, it's very difficult. The issues inside of medicine to think you're gonna fit it into one documentary, and so the the the flows of this doc, suck it up buttercup, how did it start, and then what is the main mission vision behind it now?

SPEAKER_04 7:08

Yeah, sure. So it started, and I gotta give credit where credits to you. Marianne Wilbur uh is a fellow physician. This was her inspiration. She wrote a book called The Doctor is No Longer In, and that was the genesis of it. But it had, as David said, it had very much a evolution from initially kind of looking at the mental health pull, burnout, physician suicide to really where it landed was pulling the curtain back for the American public, how greed has slash is destroying our healthcare delivery system from a multitude of stakeholders, physicians, nurses, patients, former executives, celebrities. And it it has a unique twofold call to action that's overarching. One, unlearning, learned helplessness, like your words matter, your actions matter. You know, a lot of our colleagues are just trying to survive and get through their day. And then the other one is to accelerate an impact network, sharing stories, collaborating, working together, finding, coming up with other solutions. But the so the first three-quarters of the doc is really kind of painting this picture of private equity, health insurance, PBMs, the mental health toll, all these other things in a you know, raw way. So the average person can really say, oh my God, this is what's actually happening through storytelling. But then the last 20 minutes of the film is really highlighting positive examples, ways forward. And if you really are paying attention, there's like 20 calls to action in there. And so ultimately we're trying to educate, empower, and inspire people to play their part is really the goal.

SPEAKER_00 8:38

How long have you been working on this?

SPEAKER_04 8:40

Uh we first filming was November of 24.

SPEAKER_00 8:44

Okay.

SPEAKER_04 8:44

And the film was, you know, quote unquote finished in March of this year. And I was telling David, we're on the cusp of releasing it on video on demand.

SPEAKER_03 8:52

Oh, that's exciting. Nice.

SPEAKER_04 8:54

Yes. It which anyway, I could get into it. You know all this. You don't know what you don't know, right?

SPEAKER_03 8:59

Yeah, contrary to popular belief, when you finish a documentary, uh, it's not done. If you guys have been wondering where Anti-Diet Diet Club is, it's for that exact thing. It is, I I feel like what I've learned about being in the producing space in this world is when push comes to shove, creating a documentary is 20% of the effort it takes to actually get the impact you want. 80% is in the back end stuff that is not on screen.

SPEAKER_04 9:26

I agree with you a thousand percent. Like the amount of effort behind it, behind the scenes is incredible. But it you know, I consider this project a labor of love. I really do. And one of the one of the uh inherent advantages, I think, is the topic is a hot topic right now. And the way we set up the infrastructure of the company is we already have this sort of built-in support system. So it we've really been debating the best way to get it out to the masses and and ultimately land it here. Now, do I think it'll get on a streaming service down the road? Yeah, when the time is ready to do. Um, but for the time being, within probably a matter of days, people will have easy access to the stream.

SPEAKER_03 10:02

Oh, that's awesome. Awesome. That's really cool. Now, uh, fun enough, some of the different uh people you have in the documentary, uh, one of the ones that is fascinating, you got Mark Cuban in. What was that process like? What were the main things he was he he speaks about? I'm sure you're gonna be like, well, go watch it. But what are some of that that what was that dynamic like?

SPEAKER_04 10:22

Well, it was amazing, surreal. Um, so that came about through a friendship I have with Dyke Drummond, who Dyke is a champion for physician well-being, has been doing it for a long time, and he's been good friends with Mark for since they were in college. And so the the backstory is I emailed Dyke saying, Hey, we want to interview you, and oh, by the way, if you want to tell Mark, that'd be great, is literally while the email went. Next thing you know, I'm getting an intro to Mark, and he clearly expressed interest in what we were doing and agreed to do, and it was gracious enough to do an interview. And the interview was kind of the the two the tale of two kind of stories, if you will. The first half was very, I would say kind of business-oriented, talking about PBMs. And I interjected about halfway through and told them really what the calls to action were going to be around the film, and that I thought by the time this got out that there were going to be probably hundreds of thousands of physicians who were aware of this product and or tethered to it, which clearly that's kind of a big deal. Um, and that that is actually kind of the reality of where we're at with this. And so the the dynamic of the interview changed completely after that. Guard came down, he was having a blast, F-bombs were flying, you know. Um which, you know, and that's what we wanted. We we wanted somebody outside of the healthcare space to really say how they feel. But not only that, like Mark has a lot of great ideas for moving things forward. And for somebody of that stature, influence to be vocal, man, it was a blessing. Total blessing.

SPEAKER_03 11:54

And it's such a dance because like we were talking about before, um, as we get into like the DPC uh concierge side of this conversation. The way my dad's always said it, which I would very much respect, is like for the longest time there was no business acumen in healthcare. It was just like doctors doing what they were gonna do. And the the classic I had a cousin of mine who was in logistics who was in logistics for a large healthcare system, and it's and he always make the jokes goes, Do you really need six different types of gas? Can we like figure out some systems to get it down to like four so we can get better price point and we can get better volume plays? Like he'd always tease us, because I mean, yes, I understand there's six, but can we can we get away with four? And like that kind of tease of but then uh it was pure patient focused, which then if if systems are losing money and the systems are falling apart, it doesn't work, it's gotta break even. But then we've gone the opposite direction, which is the humanity in healthcare is pretty much gone. And it's seeing a logistics guy who's like 24 years old. My dad will never I'll never forget him telling me the story. He was in his last five years of interventional cardiology in the cath lab, and he's got this kid that's like 25 years old on a clipboard and a stopwatch, stop watching his movements of doing an intervention on whether he was doing uh angioplasty or whatever he was doing, someone's literally doing this timing to him. And at the end of it, he got critiqued on well, why didn't you do it this way? And dad looked at me and goes, Because you're 25 years old, you're not a doctor, you have no idea why I did what I did. And so there's there's two very polar sides to this.

SPEAKER_04 13:39

You're right. I mean, we one of the clips in the film, Don Berwick, um, who was a head of CMS for a while under President Obama, relates a story of a radiologist. They put a metronome on his desk. How fast he should be reading x-rays. That's ridiculous. Well, I mean, if you're the patient who's that that's your film, you don't want artificial time pressure dictating how long that clinician can take a look at the images. I mean, come on. You know, I you know what's interesting though, David, too, what I've seen in my career at multiple levels is if you take care of the patients and really do what's best for them, whether it's time or effort or whatever, everything tends to fall in line. You know, and and and when that happens, typically those entities are financ do well financially, but that's not where the focus is most of the time. Most of the focus is on what's the ROI in three to six months, 12 months, whatever, and be damned the rest of it, yeah. Um, which is unfortunate.

SPEAKER_00 14:38

Well, I mean, you uh you've said that a lot of the beginning of this film is on like the greed and all these issues with healthcare. And obviously, I'm sure you saw that while you were working before you started the film. But when you started doing the documentary, was there anything that surprised you or that you learned that was worse or better or just completely different than maybe you expected?

SPEAKER_04 15:03

I think after a while, nothing surprised me that I was hearing. It was some of it was just insanity in terms of private equity takeovers. I mean, I think if Steve Abelowitz, who's in the film, you know, pediatrician, built his practice for like 25 years, COVID came around, and he was kind of worried about how he was going to pay his staff. And so he ended up selling out to private equity, who then fired him from his own practice.

unknown 15:27

Like, what?

SPEAKER_04 15:28

So Steve is kind of a hero. He's actually suing that company, and it's been in the LA Times and all these other things. I think some of the things that bothered me the most were like the scapegoating of clinicians or nurses who were trying to do the right thing, trying to speak up, trying to advocate for either their colleagues or their peers, and were either you know vilified or cast out or fired or eliminated. Those are the those are heartbreaking. I mean, I even experienced that too. When I was pushing back against the C-suite, I know they hated me by the end of it. Um if they could have figured out a way to fire me, they would have. Um but I think they know I would have had a lawsuit on their desk the next the next morning, probably. But anyways, uh I digress.

SPEAKER_03 16:12

Oh no, I was I was just listening to the conversation.

SPEAKER_04 16:14

Sorry, sorry.

SPEAKER_03 16:14

Sorry, you totally get it.

SPEAKER_04 16:15

But so yeah, I mean it's it's it's scary some of the things that happened. Happened.

SPEAKER_03 16:20

And when it's fascinating to just that dynamic, and correct me if I'm wrong, but this goes back to the earliest conversation talking about burnout and that whole process, how much Jana and you have talked about that kind of when when you're put your s when you're when you get put an impossible task. Like our previous episode was on Lara kind of sh sharing the fact that she used to have 3,000 patients. And you sit there and go, What do you do? And it's that's the 20 patients you see a day plus the a hundred that hit you up over a week or two period time period of all that you need, and all you can do in those situations is get numb to it. And like how is that how is that experience from yours? Was it very similar to his?

SPEAKER_00 17:06

Well, I think so. I mean, I always find it interesting too when physicians who've been practicing longer than me, I wonder too, if what you maybe noticed was different about healthcare when you started versus by the time you felt burned out. I don't know if that played a role because I came into healthcare right at around COVID, and then I felt like there was a huge shift in how people felt about healthcare and how they uh respected it or didn't. So I don't know if that played a role. I don't know if you have anything to say on that.

SPEAKER_04 17:35

Yeah, I think there was an evolution of it for sure. I mean, in full transparency, I started when we were still doing paper charting.

SPEAKER_03 17:42

Um and so I changed because then I go you go set one step farther and you go to dad's age, and he was out before the transition. He got to see just the peak of the problems. But everyone always says, like, if you were a doctor in the late 80s through two early 2000s, like that was the time to be a doctor.

SPEAKER_04 18:01

Well, and there's definitely, I mean, there's oh man, there's so much that's changed. I'll give you I'll give you a story uh that might encapsulate this quite a bit. So I used to attend the the board meetings uh at our critical access hospital, whether I was vice chief of staff or chief of staff, and I got into the habit of being okay with vocalizing concerns or ideas, etc. Um, and there was an older physician there, I love him. His name is Dr. Leeser. Um, I think he's still around. But uh, anyways, he would say stuff and oh, you know, you young docs, you're not as tough, and all these other things. And finally, one meeting I couldn't take it anymore. And I go, Bob, this is in front of the whole board. I'm like, Bob, you wrote your whole note on a three by five card. We have notes that are 17 pages long for someone who has a cold. He never said another word.

SPEAKER_00 18:47

That's awesome.

SPEAKER_04 18:48

It but and it was that mutual respect, but I think that encapsulates the evolution of the you know, the clerical burdens, the administrative burdens, the box clicking, all these the coding issues, you know, the prior authorizations, all this frankly, non-value added crap that impacts care delivery. They didn't that that burden wasn't it was there, but it wasn't nearly the same as it is now. So back to your question, have I seen that evolve over time? Yeah, and did that contribute to my struggles? 100%. I used to do prior offs and crayon. I would get so fed up with stuff like I would fill it out in crayon and put a smiley face, and every time I did that, it got approved.

SPEAKER_02 19:29

That's funny.

SPEAKER_00 19:30

When when there was the transition from paper to electronic, do you feel like that was did that contribute some to the burnout than you're saying? Or yeah, okay.

SPEAKER_04 19:41

Yeah, I mean, you know, so there are pros and cons to every type of document documentation that you're gonna do, whether it's paper charting, dictating, whatever, right? You know, the way I describe it to uh individuals, and I write about this, you know, imagine if you're the an airline pilot, okay? And you're having to fly the plane and document what you're doing at the same time, and paying attention to the navigator, and doing the you know, acting as the steward or the stewardess or whatever. That's what it's like having an EMR. And you've got you're trying to do this in 15 minutes for people in the feed for service world. It's crazy. And a lot of times it is not user-friendly, it's like learning another language, and we're supposed to be documenting it, thinking, making decisions, writing prescriptions, ordering tests, all these other things. It's silly. It's silly. You're taking your highest value resource and turning them into at times a data entry clerk.

SPEAKER_00 20:37

Oh yes. I felt that way. I felt like half my job somebody else could do if they just sat down with the patient and asked him a few questions. But then it took up our time. And then the things that patients cared about didn't actually get addressed. So I'm totally with you on that.

SPEAKER_04 20:53

I used to, I became the master of delegating uh with my medical assistants. We had a great relationship. So I would see the patient, I would pre-chart a little bit, and then I would have a little crib sheet with all the standard things that I ordered, and I would have a red pen and I would circle everything that needed to get done. They would order it all, I would finish my note, I would review the orders, and then sign off on them, and it worked brilliant.

SPEAKER_00 21:16

Um really lovely. Did you have two medical assistants? I did. Yeah, I never got that, Joy.

SPEAKER_04 21:21

They never gave me two. I almost I at one point I was pushing for a third.

SPEAKER_00 21:25

Oh my god. See, that would have been helpful, but we were never allowed to have them.

SPEAKER_04 21:29

I yeah, I think um, as you're probably figuring out, I was also somewhat vocal about things. I think that's great. And advocated for things quite a bit. Um, you know, for better or for worse.

SPEAKER_00 21:41

Well, no, I think it's great. I mean, I felt like I was on the opposite side of things where I was like, I don't like any of this. I don't feel like anyone's gonna listen to me, anyways. So I just kept my head down, did my thing, and then I got out finally. So I think it's great that you were vocal on it. Um, it would have been nice if I could have. Participated in that as well. But I did it my own way.

SPEAKER_04 22:02

Well, and I think that speaks to like what we're doing now, right? I mean, there's lots of different ways to see patients to care for people and add value. David and I were talking about this before. When I stepped away, I was 46 years old. A physician in the prime of their career, going from seeing at my peak, probably 6,000 visits a year to zero is a big hit to the that local community's healthcare delivery. And so to be able to come back in a model like with you know with Plum Health doing direct primary care, and granted, I'm not seeing the volume I was seeing before, but it's infinitely more than zero.

SPEAKER_00 22:39

Um, you know, so right, because I've heard the critique of people doing what we did and leaving traditional care and that we're taking away from the patient care that should be there. But my argument always was I would just have left it altogether if I wasn't doing what I'm doing now. And that's a worse option.

SPEAKER_04 22:56

Agreed. I agree with you 100%. And I think a lot of our colleagues would do that given given the current landscape. And that's scary if you think about it, right? Um, so I think having these other care delivery models, whether it's struct primary care or concierge, are of value, right? And you're still caring for people, as am I, as opposed to not.

SPEAKER_03 23:14

Well, that's where I think this is a perfect transition to this kind of comp complicated situation, which obviously suck it up buttercup in the documentary. We could sit here and talk about the because at the beginning we we kept saying PBMs. I'm sure most people on this have no idea what a PBM is and all these other issues. But in particular, concierge medicine, direct primary care, membership model. What is the primary per what's the primary pull that it's helping? And why are you you guys why did you guys go into it? Like how did getting into membership-based model medicine help fix some of the problems you were having?

SPEAKER_00 23:58

I mean, how why I did it is because patients were telling me indirectly that this the system that they were in was not fulfilling their needs. And so that's why I left and said, what can I do to fulfill their needs? So I don't know what your experience, if it's similar to that at all.

SPEAKER_04 24:15

Mine's a little different. Um, because I had been away for a couple years from full-time care. I had done some episodic care. Uh, we called it chronic disease management, where I was seeing people, you know, for extended periods and trying to sort of flesh out what the you know, the needle in the haystack was at times for them. Really, me getting involved in a drug primary care. I had been interested in it over the years instead of kind of paying attention from a distance, if you will. Paul Thomas reached out to me and was like, we're looking for a medical director in Lansing. And I was like, Paul, I'm not looking for a job. Um I seriously, that's exactly what I said to him. Um But he he didn't deter him and he kind of explained what they were looking for. And as I thought about it more, it sort of was this there was this piece of me that had been missing, and it was caring for other people. And the more I thought about it, the more I was like, oh, this sounds fun, and I can do it. I'm not running around like a chicken with my head cut off. You know, I see 10 people a day, my panel's about 500. I mean, literally yesterday I was messaging people I was concerned with, independent of them having a visit, just checking in on them. And they're so people are so appreciative, right? And so to me, it's it's a way to deliver high quality care. Access is way better, costs are better. Um, you know, so it's it it's really getting medicine back in my mind to to like where it should be, you know.

SPEAKER_00 25:35

Um so but I do think that is the same idea as us for the fact that that's those are the things that patients want. They want their physician to contact them when it visits and to spend the time with them, and they want to know that they're cared for. And so I think that's why most of us, I would assume, go into a direct pay model.

SPEAKER_03 25:56

And the whole angle, correct me if I'm wrong, the direct pay model, the way it creates this opportunity is insurance doesn't dictate how you control your time. Is that basically the meat and potatoes?

SPEAKER_04 26:11

That's yeah, that's a big part of it. The the way I simply describe it is you're eliminating you say you have a physician here and up a patient here, you're eliminating all these middle people between. You know, uh when I'm done seeing a patient, they're like, well, you know, do I pay my bill? What do I do? And I'm like, no, you just make a follow-up and you can leave. That's like we're done. Um so yeah, I mean it's it's it's in my mind, it cuts out a lot of ways, honestly.

SPEAKER_00 26:34

I mean, I I do agree with what you said, David, that it's a lot of the things that I felt like I had to do for the insurance company. I don't have that pressure over my head anymore.

SPEAKER_03 26:45

Now, here's one that I find interesting, and like the we were talking about in the hallway. This it is fascinating to me because I know you experienced this to a degree. I don't know if you did, but the when you because you took a time you took a pause. When you went into concierge medicine, and then obviously you eventually went to DPC, did you have other clinicians having this almost like you're leaving the system? You kind of asked, we we said it earlier, which is like, why are you leaving the system because you hurt us because you leave? And it's like, well, if I don't leave, I'm going to zero patients. At least this system I'm seeing 500 or 300. Um, did you guys both have that kind of resistance from other clinicians in like the the primary care space?

SPEAKER_00 27:31

I didn't feel it directly from other physicians. It was more the conversation around anyone going into say concierge that I heard it through. So I don't know what your experience was.

SPEAKER_04 27:42

Uh yeah, probably not quite as direct, I would say. I think in part because I was doing other things from an advocacy perspective that probably offset that. But I definitely would hear those rumblings in my conversations. I mean, unfortunately, shame is inherent in medicine and in particular in medical education. And so when you're not quote unquote towing the line, yeah, some of our colleagues tend to shame you and and make you feel bad. And then that that's not helpful.

SPEAKER_03 28:09

Well, the the reason why I bring it all up, too, is like this resistance, because obviously there are weaknesses with membership medicine, like DPC concierge, like there's there's now money involved. Now, I'd argue when when you look at the numbers, it's nothing compared to what people pay in in sh in healthcare in general. It's pennies and a dollar from anything most people experience. But with this kind of momentum towards it, especially in primary care, why does it seem like that it's still very unstatus quo to be jumping to DPC? Like again, most doctors are not, they're staying in the big systems, they're too afraid to make the jump. Or what what do you guys think is the big issue that more doctors are not making a leap? Like we were talking about before, like you uh plum is trying to grow and trying to, but there's there's an angle to educating practitioners to be like, hey, this model is better, but there's like this big kind of resistance to it. Have you guys experienced that?

SPEAKER_04 29:14

Um Yeah, I mean, I I think there's lots of layers to that, David. I I think some of it's education. Um, I think a lot of people don't understand concierge or direct primary care. And I think that's an opportunity. I mean, what you're doing here is incredible because you're not only teaching patients about it, but you're teaching clinicians who may or may not be aware of it, right? So the these kind of formats are very powerful. So kudos to both of you for doing it first off. But I I think there's also some fear. Um, and I think a lot of that is financial fear, financial uncertainty. It's new. I mean, I even hear it from patients. They come in and they're like, is this a Ponzi scheme? How does this work? And they're serious. They're like, how can you guys do this? And and then I explain it to them. Like, we don't have 25 people who are sending out claims and doing codes and all these other things. And and they're like, oh, and it starts to click. So yeah, I I think some of it's education, some of it's fear. And a lot of people are afraid to challenge a status quo, too. I mean, that's pervasive.

SPEAKER_03 30:14

Well, the one that I mean I always think is a classic, which is um I argue most of the time it's never intentional. People humans love to create big old like there's a puppeteer over here. And like I think the world's way too complicated for two people going, Yes, I know this person's going over there, so I'm gonna do this. It's like I just I'm I just think it's a lot of people making short-sided decision making that leads to a lot of long-term problems. And the reason why I say that is you sit here and go, the average physician's in two hundred thousand, three hundred thousand, four hundred thousand, five hundred thousand dollars of student loan debt. And yeah, they may hate the system, but what are they gonna do about it? You're in a half a million dollars of unbanked corruptible debt, so you're kind of pot committed. Like, what are you you gonna you're gonna you're gonna jump ship and start your own thing? Well, what happens if it doesn't work? And yeah, the amount of resistance out of I don't think people in the outside of medicine don't realize that yes, doctors make better than an average wages, but they're usually in so much debt.

SPEAKER_04 31:21

Well, and that that that you're right, David. I mean, a lot of our colleagues don't pay out their student loans until they're in their 50s or 60s, even. I mean, imagine that. Like you've got a mortgage on top of your mortgage, you know, on top of potentially your mortgage from undergrad, right? Um that's a huge deterrent to people speaking up and and and breaking the mold at times. Um but that's why all these other efforts, you know, like empowering people and trying to get them to realize what is out there and unlearning helplessness. There are other options. There are people that can mentor you through this and walk you through it. And these paths are open, you just have to look for them. But think about our training, right? Be more autonomous, be more resilient, just work harder, put your head down, keep moving forward, take care of the patient, everything else will work out, right?

SPEAKER_00 32:08

Um put the patient first, always. Now you mentioned learned helplessness, I think at least twice now. Can you tell say more about that and kind of we're why you bring that up?

SPEAKER_04 32:18

Yeah, yeah. So I when we were going through the calls to action for the film, it you would you probably would have laughed at some of these conversations with me with like presidents of medical societies and chief medical officer of this, and Todd, what's the call to action? It needs to be super granular. And I would every time I heard that, I'd be like, We have a five trillion dollar mess. Yeah like this is not gonna be fixed in three months. Like, come on. So learned helplessness goes back to a study, and I I can't think of the name of the researchers who essentially they put a dog in a cage and shocked the dog. And it was blocked off, so the dog couldn't get away. And then they they opened the door and kept shocking the dog. But by that point, the dog had given up and just lay there and continued to be shocked. That's kind of the notion of learned helplessness. And a lot of our colleagues, that's how they feel for a multitude of reasons. They feel like, oh, my I'm only one person. What does it matter? If I say something, I might get fired or I might lose my job or lose my income or all these other things. So that's kind of where the notion comes. And so we're trying to convince people that you need to unlearn that a little bit. You need to understand like your words and your actions and your efforts do matter, even if it's just in the context of how you treat your colleague.

SPEAKER_00 33:31

And that's direct. And then you're saying at the physicians and anyone working in healthcare that learned helplessness.

SPEAKER_04 33:37

Anybody who's frustrated with American healthcare delivery. So everyone. Because patients we need patients involved too. I think where the magic sauce is going to be in terms of reform and getting further upstream is getting patients involved. Um, and they need to understand the landscape a little bit better and then get have guidance as to where they can put their energy, whether it's you know, time, talent, treasure, whatever, whatever bucket they want to pull from, they need to know how to to to how do I say this? Um get involved. Get involved.

SPEAKER_00 34:10

How would you if a patient said, well, how can I do that? Like do you have specifics?

SPEAKER_04 34:15

Well, I could I how long do we got? Uh what you got? Yeah, yeah. So I could well actually, so even just in the book uh I wrote with my my my former patient Joshua, there are hundreds of things in that book that people can do. As simple as thanking your physician, asking them how they're doing. As a physician, when somebody does that, it's different. And in the fee for service world, I guarantee you're gonna get a couple extra minutes with that clinician. Send them a thank you card. Those are simple things, really simple things. Then you can scale it from there. Maybe you get involved with legislative stuff, maybe you get involved with ballot proposals. Um, there's some some ballot proposals around the state uh community action plans um that people are basically offering every other year sort of a report to city councils as to how healthcare access and affordability is going. Maybe you support that, maybe you put a little bit of money behind a nonprofit. Um maybe you watch the film and learn something. You know, right? You know, that's obviously somewhat self-serving, right? But but there's a bazillion examples out there. Uh, I think people just they don't know where to put their energy, you know.

SPEAKER_03 35:27

Here's uh this is a complete tangent, not on the list of things we're talking about, but it's it's a very touchy subject because they're trying to get it through legislation. The idea of it's like everyone trying to make like you said, it's a $4 trillion problem. Five, sorry, five trillion dollar problem. And going up. And going up. And this idea that there's one boogeyman is never the issue. Like insurance has their roles, large healthcare systems have their roles. Uh whether people want to admit it or not, as someone who used to pay 400 pounds pre-diabetic and all those problems at the age of friggin' 14, the average patient and the average American has their roles on why this system is where it's at. And so from the private equity world, they're trying to make a federal law to ban private equity in healthcare. Number one, what's what's the good outcome of that happening? And what do you think are the unfortunate situations that happen if that does happen? Because like just like everyone, there's not nothing has a zero cause. So like zero fact. So it's like, what's the positive? And then what's what's the potential negative from your from your view?

SPEAKER_04 36:35

Well, so and I'm gonna be careful how I answer this question, right? Because at large private equity is very problematic in the healthcare space, without a doubt. I mean they basically they come in highly leveraged, extract a lot of profit, reduce staff nurse-patient, doctor-patient staffing ratios, et cetera, which ultimately studies have shown reduces quality of care and bad outcomes increase, et cetera. So I think the primary positive, in my opinion, as a result of doing this would be having increasing clinical leaders making decisions for the healthcare system at large as opposed to no offense to my friends with NBAs, but people with MBAs making decisions, right? I was talking to my wife, and I don't know what we were talking about. I was talking about could I be a CEO of a hospital? She's like, You can be a CEO of a hospital, you don't have an MBA, and I'm like, I'm pretty sure I could be a CEO of a hospital. I know how to take care of patients, which is what we're actually there to do. The CFO can have the MBA and figure out the numbers, right? So I think that would be one of the biggest benefits to it. Are there instances where private equity is doing good things? Yeah, there are. And would that be negatively impacted if it was sort of black and white carte blanche? You know, maybe that's not the right word, but taken away, that could be negatively impacted.

SPEAKER_03 37:54

Well, I just sit there and like the just like everything in life. Nothing has like there's always some effect. So it's like, I think the positives will definitely outweigh the negatives, but is it these maybe lower tier outskirt hospitals that are basically subsidized through a PE to help something else? If they lose that that kind of safety net, do they go under because they can't do what I don't know what I don't know what it would be.

SPEAKER_04 38:19

Well, that that's happening regularly right now. Rural hospitals are closing left and right, and in part, that's often the playbook. Private equity firm comes in, starts slashing services, revenue goes down, reimbursement goes down, more service lines are cut, volumes go down, etc. And then you get this death spiral. We're losing rural hospitals on a weekly basis. So yeah, the current model is not working in that regard. There's actually a great book on this. Um, I can't think of the title of it, but it's by Matthew Hartlison. Okay. He's a nurse that wrote it. Um fascinating descriptor of what happens to a rural community hospital and how it gets to that death spiral.

SPEAKER_03 38:58

Oh, I couldn't imagine.

SPEAKER_04 38:59

Well, it's like I think it's how healthcare dies, I think is the name of the book.

SPEAKER_03 39:02

How healthcare dies. I mean that that that whole dynamic, I'll be the first one to say I'm biased. Like I so I went to I went to CMU for undergrad, and uh I had a appendastitis scare, and there's plenty of great physicians in the Mount Pleasant area. But in the process of my appendicitis scare, my father and my and myself were like, if I'm getting surgery, I want it done in Grand Rapids where there are quote unquote better physicians and better systems. And it's like, yeah, that's my own bias, like that.

SPEAKER_04 39:38

Well, i mean, biases are inherent, right? Um but that's part of uh why again, why stuff like this is so important, like people doing op-eds or podcasts or writing books or creating films to educate people, you know, the realities of what's going on. Uh because the more we educate the public, the more they're gonna decide what they want to do with their anger, their frustration. Matthew Zach, we interviewed Matthew Zachary, he's a kind of a mini celebrity patient advocate. He talks about people don't don't know what to do with their anger. They don't know what to do with their when they're pissed. And that's the core of advocacy.

SPEAKER_03 40:14

That's what he says. Well, and then you got on a fun note with another another sta another person you had on the podcast, glaucoma flecken. Or sorry, on the in the the uh documentary, his ability to take very complex things, make it funny and engaging is incredible. Before you got him on to the documentary, I would send Laro videos all the time of glaucoma flecken on different things. And his his little uh antics of cardiologist versus nephrologist is hysterical. Oh yeah. And uh, how is bringing him on uh to the to the doc? And like what was what's his from your point of view, uh, what's his main draw and desire to try to do for the doc?

SPEAKER_04 40:59

Well, the doc in particular, I think um he he got involved for a couple of reasons. His partner production manager, Shanti Brook, and I had a conversation about a year and a half ago. Maybe a little less than that, but she kind of saw the vision of it and sort of the value and the the synergy between our worlds. And so Shanti was kind of the one that said, Hey, Will and Kristen, you guys really need to do this project. And to their credit, they they you know they trusted her and and and they did. Um, and since then Shanti and I have become good friends, and she's much more involved with the the the production company at this point. I think the real power to the interview between Will and Kristen, aside from they allowed us to use some of his funny clips, and there's an Easter egg at the end of the film with him and Senator Warren, um, which we got approval from Senator Warren's camp to use it. I mean, you think of all this stuff like how did all this happen? But there's power in the two of them talking. And in my opinion, hearing from Kristen as the spouse of the physician was an incredibly powerful piece of it. Because the two of them kind of go back and forth. And at one point, even Will says something to the effect of you don't know exactly you don't have to know exactly what to do to fix this. Right? We don't all have to have the answer. And he makes the the point that speaking up counts, right? And and and so that was a very powerful thing at the end. Plus, he's funny, and you know, he just he talked about we need to educate toddlers on deductibles and all these other things. He's like, let's start them early, you know, teach toddlers about deductibles.

SPEAKER_03 42:27

I I sit there and his his uh his spoof on orthopedic surgeons is great.

SPEAKER_04 42:32

Or orthobro. Yeah. No, he they're they're they're they're fantastic. And he's gotten Will in particular has gotten much more vocal with issues that are out there like targeting problems because there's power in social media, and his role in the Eugene Emergency Physician Group battle against corporate medicine was was huge. I mean, the governor got involved in Oregon, um, and and that little group of 35 won.

SPEAKER_00 43:01

Did they really? I was following along with that, but I won.

SPEAKER_04 43:04

They won. And I went and had dinner with a handful of them. I was like sitting there going, I could be your guy's dad. So you could I'm like, you guys, I couldn't believe how young some of them were. It was so cool to see that they had the courage to stand up to a healthcare health system that really wasn't doing the right things. It was amazing.

SPEAKER_03 43:23

When we talk about courage, I mean that's that's always the the big one, too, is like, yeah, like I I do love your quote with the idea of there's so many people that say the healthcare system's too far gone, and then it's always the whole chalk it up to well have this group of small people, and I think that's just such a dangerous position. It's it's it's gonna take communication between all levels, working through. Because insurance, as much as you want to hate them, they have their pla like they there's a place for it, there's a value of what they do. Are they making mistakes, thinking short sighted? Absolutely. But I couldn't imagine like I would like a great one to me is on this subject of trying to make sure that we understand the complexity of the situation is okay, we can all agree GLP ones are incredible. It's the first time we've had a drug actually help with weight loss. Isn't that amazing? Well, over half of America is clinically obese. If we put half America on GLP ones, we bankrupt our entire insurance. That alone. Like we can't we can't afford it. Now you can argue pharmaceutical companies are overprofiting on them, but even say you cut it by two-thirds. The numbers still don't work. And so it's always this game of trying to make sure we take on every if you want to, if you want to really make incremental change, sustainable change, it's holistic. That word does get bogged down by the social media gurus out there, love saying the word holistic. But it is, it's like there's a holistic change. It's not private equity, it's not just doctors, it's not just insurance. Everyone has their piece of the puzzle that if they give 10 to 20 percent, we could actually create a massive shift. It's not one that's gonna make this shift happen.

SPEAKER_00 45:10

I think it's a lot of pieces.

SPEAKER_03 45:12

A lot of pieces. And I don't like jigsaw puzzles. Lara, Lara loves jigsaw puzzles. So if if if this if I could create the mindset that a jigsaw puzzle was like the healthcare system, because I like that. I like thinking, okay, this has this player, this, but like playing, like actually working on a puzzle, I do not enjoy that at all.

SPEAKER_04 45:32

I don't it's it is a complicated mess right now, is probably the best way to describe it. I think there are solutions out there that we haven't heard yet and opportunities that we're not aware of. And I think some of them are gonna come outside of the healthcare space, to be quite honest with you, which is why the concept of an impact network, as you were kind of alluding to, as you were just you know describing, David, is so important. You know, because there might be somebody out there who has an amazing, like I've heard the concept of healthcare delivery as a public utility, right? Let's think about the fire service if it operated in a fee for service model.

SPEAKER_01 46:10

Yeah.

SPEAKER_04 46:13

Pretty sure we'd have a lot more fires going on. Um, you know, is that what we want? No, not necessarily. It's it's fascinating when you think about healthcare delivery as a as a as a public utility or you know, community-based delivery, or community-based care. The answers are are there. They may just not have shown themselves just yet.

SPEAKER_03 46:33

And your doc does a fun job of number one inspiring for the opportunity for change and then starting on the momentum forward. I'm looking forward to seeing the final the final piece of it. I saw I saw a version of it a year ago in California, and I haven't seen the final yet.

SPEAKER_00 46:50

I only saw the what what is it called? The sizzle.

SPEAKER_03 46:52

You saw the sizzle.

SPEAKER_00 46:54

Sizzle reel. That's all I've seen. So I'm excited to see it. Yeah. It's in a couple days.

SPEAKER_04 46:59

Yes. Okay. If it's not out by this weekend, I I might lose some hair.

SPEAKER_00 47:05

Or Ann Gray's. We'll have to put that in our next newsletter for our patients.

SPEAKER_03 47:09

Oh, we definitely will.

SPEAKER_00 47:10

Yeah, that'll be great. Go watch this.

SPEAKER_03 47:13

Well, it was incredible to have you on here. This is a great conversation. Any last like general macro thoughts on Suck It Up Buttercup as a documentary? How would you uh like someone to have the intention going into it kind of think about?

SPEAKER_04 47:29

Yeah, I mean, I think with the film, it's it at times it's heavy. I mean, and there's some there's some stories in there that are heartbreaking, you know, workplace violence and mental health and all these other things. So you've got to be in the right place, you know, to watch it, I think. Um but if you go into it with an open mind and an open heart and really are paying attention to some of the messages and what people are saying, it is loaded with opportunity for people to get involved in one capacity or another. And so that's how I would want people to go into it. And then if people are looking for opportunities from there, I mean, you reach out to someone like myself or reach out to the two of you or get involved with the work that you're doing, or join a, you know, join your practice. I mean, these are all ways to make a difference, right? Or get better care, frankly, depending on where you're coming from. So yeah, I open heart, open mind is what I would suggest. And I always advocate for you know, kindness and checking in on our colleagues too. You know, we get in these silos of care delivery, and there's a lot of people suffering, not just patients, but clinicians too. And so being kind and asking people how they're doing is also incredibly important.

SPEAKER_03 48:37

100%. Well, I mean, Lara brought it up on last week. How many, how many uh uh different clinicians you had that you talked made three words to in a year because you had to keep your head down.

SPEAKER_00 48:48

Like I said Yeah, we worked in the same office and never talked to each other.

SPEAKER_03 48:51

Yeah. Yep.

SPEAKER_00 48:53

It's a real problem. I 100% agree. So thank you for the work you're doing. Oh yeah. It was I think amazing to talk to you again, and we're looking forward to watching Suck It Up Buttercup. And anything else to add, David?

SPEAKER_03 49:07

That's it. Have a phenomenal day, everyone. We'll talk to you all later.

SPEAKER_00 49:10

Bye.