Lessons - Why Your Doctor Doesn't Have Time to Actually Help You | Brian L. Strom - Fmr Rutgers Chancellor & Public Health Researcher

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In this lessons episode, discover why trust in healthcare declines as medicine becomes more corporate and transactional, understand how misaligned incentives can prioritize treatment over prevention, explore how better use of healthcare professionals can improve care, and uncover how population-based healthcare could shift the focus toward keeping people healthy.

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It actually seems just very, very anecdotally without the data to back it up, just through a casual conversation, it seems like more people are trying herbals and Eastern medicine and all of these things that don't seem to be Western.

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And it's so interesting because I think there's cultures that seem to default to Eastern medicine or herbal medicine.

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I mean, I'll give you an example.

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Growing up, I didn't, it was just regular drugs.

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I don't even know how else to describe it.

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It's just like Western medicine and doctors and prescriptions and antibiotics and anything else.

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And then, so my better half, she's a couple different things, but her mother is Jewish, Israeli, and her dad is Russian.

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And she has tried so many different...

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herbal things to get better and when she's sick the default is herbal this or herbal that or try the end there was like um like a a chinese doctor that she went to go see one time i'm like i don't understand any of this isn't isn't from my my world or what i knew growing up so i feel like and maybe just because i have proximity to it but i also hear it in conversations uh uh

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Not a complete lack of trust in Western medicine, but some lack of trust in Western medicine.

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And I'm so curious why you think that's happening.

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And if I'm incorrect in that assumption, you could tell me that too.

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But I felt that in conversations.

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I think you are correct in that assumption.

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Widely used, and the herbals, non-typical treatment is entrusted, are taken widely, and people instead take herbals and other things.

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And it does come a lot from lack of trust.

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Part of it is that given where healthcare has come and now it has evolved, physicians don't spend much time with patients.

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And as healthcare has more and more become a business, rather than sort of the solo practitioner doctor who comes to your house and whatever, you don't trust people as much.

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Again, if you talk to most patients, they'll all say, healthcare is terrible, except my doctor, he's great.

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And people who have a primary care doctor, and I'm biased, I'm a primary care doctor, but people who have a primary care doctor typically will trust their primary care doctor.

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But more and more as medicine has become corporate.

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And as healthcare has become much more expensive and hasn't become corporate, the times people spend, docs spend with patients is less and less.

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More of that is in front of a computer screen.

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And so the doctor's interacting with the computer rather than the patient.

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There's much less trust.

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And part of what alternative healthcare providers do is they spend more time with patients, in part because they're cheaper.

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So if you're going to make X number of dollars per hour, whatever that clinical specialty is, if you're a surgeon, they want you in the operating room.

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If you're an anesthesiologist, they want you in the operating room giving anesthesia, not spending a lot of time talking to patients.

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And I think it has definitely hurt the trust of medicine.

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I think the other thing that has hurt ironically...

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It was years ago when the people came out with the 80-hour week, which probably doesn't mean anything to you but the expanding for your audience.

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There were people who clearly were hurt and they hit the press because the doctors taking care of them were too tired.

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And so they've put in place a rule for residency.

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We talked before about treating your trainees like dirt, as endless slaves as residents, that you're not allowed to work more than eight hours a week.

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Now, the way the word resident comes from is people, they lived in the hospital.

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They were resident in the hospital.

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They were also called house tech because, again, they lived in the house, in the hospital accordingly.

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It was a commitment to your patient that was inherent in becoming a physician, that the nature of professional ethics was your patient comes first, and you stay in the hospital until your patient's feeling well.

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You do whatever's needed.

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The 80-hour week, the rule imposed because of fear that people were too tired, made doctors into shipwriters.

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That at the end of your 80-hour hours, you have to leave or the program is penalized.

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in accreditation.

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So, it's changed the character of medicine and our trainees completely with that.

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And I think it's a big loss to physicians in terms of self-worth, but it's also a big loss in terms of patient care.

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But I think the corporatization of medicine has been a big part of it as well.

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feel like there's a, an E, not an easy, but even any solution.

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to that because I mean that's not a great path that everybody's going down if they don't trust and now you have this profit machine that, not just profit machine, you have, okay, respecting the wellness, physical, mental of the residents.

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I understand where that comes into play, but when you're talking about surgeons are in the operating room, anesthesiologists are in the operating room, there's a dollar value attached to every hour of a medical professional.

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There's this

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There is this industrial complex that's driving this behavior.

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Very hard to beat an industrial complex.

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So how do you create trust or space for medical practitioners, medical providers to have that time with the patient so they can restore the trust?

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That seems to be the X factor that has to be solved for.

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It certainly is one issue, no question, no question.

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I think one way is we need to make better use of other professions.

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You don't need a doctor to do everything.

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So in my career as a primary care doc, much of what I did, you did not need a physician's training to do.

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Why did I do it?

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Because physicians could bill for it.

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What we now know, nurse practitioners, physicians assistants can often do it better and cheaper and more routine tasks.

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And so, one of the advantages we have in Rutgers Health is all of those schools are under one roof.

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So if we need more nurse practitioners, we train them.

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If we need more PAs, we train them.

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And as the world moves to more population health going forward, and we move away from feed for service accordingly, because we're bankrupting the country in healthcare and yet don't have good outcomes.

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One of the solutions is we need to think more population-based

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And we need to make better use of other professionals who can actually do a better and cheaper job of it and save the physicians who are the most expensive for the things that you really need the physicians time for.

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And, you know, it's... Behavioral Health has sort of done this using more time from psychologists and social workers and saving the physicians to write the prescriptions.

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And in which case, it's not as satisfying to the physicians that they don't have the relationships with the patients.

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But there's no one silver bullet here, but I think we've become too... Healthcare has become too much of a big corporate entity.

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Focusing not on health, it's really become sick care, not healthcare.

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It's really been... People do bad behavior,

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They get sick, they come in, they're treated for the sickness, they're sent back out where they do the bad behavior again, whether it's smoking or drinking or whatever it is that they're doing too much of.

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You're not focusing on keeping people healthy, you're focusing on only treating them when they're sick.

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That's because the current incentive system, that's what it pays.

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And that's what is changing as we move more to population now, because we're bankrupting the country.

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We're approaching 20% of the gross national product, and yet we have bad outcomes.

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The countries that spend half as much as we have better clinical outcomes.

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than we do because we focus, you know, we don't need as many MRI machines.

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We don't need as many CT scans.

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We don't need as much surgery.

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We don't need as much testing.

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We need people to think more.

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But the healthcare system, classically, doesn't pay people to think.

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It pays people to do.

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Surgeons are paid a lot.

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primary care docs are paid much more.

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Pediatricians, neurologists, and psychiatrists are all paid much less than surgeons or other higher paid specialties.

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And we're in this cycle where if you want to maintain salaries,

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income.

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We need them to stay spending all the time in the operating room and spending less time with patients going forward.

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So, it's not one solution.

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I think the closest to one solution is really population health.

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It's really sort of moving to a per patient per month basis for reimbursement where suddenly the risk of the providers, instead of being paid to do too much,

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you're taking the risk if a patient gets sick.

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Yeah, I understand.

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So now the incentives are aligned.

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Now the incentives are aligned.

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Yeah.

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But now the incentives are aligned in the wrong direction.

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Now the incentives are aligned to do too little.

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If you pay per month, it also changes the character because individual docs or individual hospital can't possibly afford that.

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One transplant patient would bankrupt you.

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So the docs come together, the hospitals come together, everything is all coming together, and that's what is happening.

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And healthcare is the consolidation accordingly in order to deal with that.

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In order to prevent undertreatment,

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You need a huge data infrastructure.

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You need to be able to say, has everyone who's gotten that COVID vaccine, gotten their COVID vaccine?

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Has everyone who has a high blood pressure, are they getting treated?

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Have they had high cholesterol?

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Are they being treated?

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You need a huge data infrastructure to do that.

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And again, that requires a mass, a scale, to be able to put that together and afford to do that.

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And so what you're saying, seeing, of course, the country is this enormous consolidation as we move.

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We're in this funny in-between now, moving from a fee-for-service system to a population system.

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And the health systems have a very hard time in different speeds in different localities.

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If you move too slowly, you'll go bankrupt.

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If you move too fast, you'll go bankrupt.

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Because right now, in many places, reimbursement is still primarily fee-for-service.

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So if you move too much toward prevention, well, you know, you keep people out of a hospital, the hospitals go bankrupt.

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but we don't need anywhere near the number of hospitals we have if we actually focused on keeping people healthy rather than waiting for them to get sick and treating them when they get sick.

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It's a little twisted incentive system.

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Thanks for tuning in.

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And if you want to dive deeper into this conversation, check out the links in the description to watch the full episode.

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See you in the next one.