FHC #233: Can physicians fix healthcare before the system breaks?

0:11Hello and welcome to Unfiltered, the newest program in our weekly Fixing Healthcare podcast series. I'm Jeremy Corr, host of PopCoonin Books and Medicine podcast and CEO of Executive Podcast Solutions. With me is Dr. Robert Pearl. For 18 years, Robert led the Permanente Group, the nation's largest physician group. His newest book, ChatGPTMD, how AI-empowered patients and doctors can take back control of American medicine, is a current bestseller on Amazon. Information on a broad range of medical topics can be found on his website, robertpearlmd.com, and in his monthly newsings published the second Tuesday of each month.

0:41Joining us is Dr. Jonathan Fisher, cardiologist, author of Just One Heart, and esteemed leader in helping healthcare professionals to prevent and address burnout. For 30 minutes, Jonathan and Robbie will engage in unscripted and hard-hitting conversation. As nationally recognized physicians and healthcare policy experts, they'll apply the lessons they extract to medical practice. I'll then pose a question for the two of them as the patient based on what I've heard. Robbie, why don't you kick it off?

1:04Jeremy Corr: Jonathan, listeners enjoyed our last conversation, and they're encouraging us to continue the discussion that we had about what we expect leaders to do. And from that perspective, I thought we might begin by looking at a seemingly non-clinical area of medicine. It's economics. I do so because I believe that this and burnout are intimately tied together, at least when we look at the practice of medicine that's coming in a few years. And I see medical leaders having to understand the forces around clinicians and help them anticipate the future, not be the victims of it. So let me start with a few numbers.

1:46Jeremy Corr: Healthcare costs$5.7 trillion a year now. it's projected to rise to$9 trillion by 2024. The U.S. national debt just passed$40 trillion. That's double what it was a decade ago. The interest payments alone are projected to be over$1 trillion a year. And employers have had to cope with a 7 % increase in medical costs for the past three years. That's a 7 % annual increase over the past three years. They're going to see a 9.5 % jump. That's according to the HR firm Aon next year. It's hard to imagine that this rate of inflation can be tolerated by small businesses, by the federal government, the bond market, with half of what federal government spends now going to fund Medicare, pay for the government's share of Medicaid and pay for the interest required in the money, our nation needs to do something if we're going to try to rein in that ever-growing deficit.

2:53Jeremy Corr: So let me start, Jonathan, by asking you, if you think these numbers make sense to clinicians, and if so, what do you think they should do, and I'm talking about from a strategic perspective, to cushion themselves for what seems to be coming inevitably. So do these numbers make sense to most clinicians? I think that a lot of doctors don't have as much financial savvy as people who are in the financial world and other industries. And it's certainly not part of our medical education. Anybody in the business world who spends all their time balancing spreadsheets, thinking about macroeconomics, I'm certain can speak this language better.

3:38Some doctors who run their own practices certainly have a better understanding of micro and macroeconomic forces that are affecting us. But I'd be willing to say that the average physician who's employed today, who is there's a 40 percent chance that they're burned out, is not keeping tabs on macroeconomic trends and policies on a government level. as much as they are, how can I get through my day, get my job done, not harm my patients and try to give them decent care? And so this is part of the problem is there's a separation between those who are impacted by these larger forces and the fact that it's affecting them directly without them being aware of it.

4:24And then the second part of your question is, you know, what What can the individual physician do about these things? We're talking about trillion-dollar deficits and big, big spending on health care, whether it's pharmaceuticals, drug prices, the cost of caring for people in hospitals, administrative costs. there's a reason why there are separations of jobs, those that are doing the care and those that are pushing the money around. And I think it was Adam Smith, you know, 120 years ago, who said that this is one of the problems with modern work, which is that there's a real separation between those doing the work and those who understand the forces affecting them.

5:15Well, that's why I started, Jonathan, with the three statistics I gave you, because we're not really talking about micro or macro economics.

5:26Jeremy Corr: You know, I could have talked about the bond rates, the 10 versus the 20 versus the 30 year. But these numbers to me are so stark. 5.7 trillion to 9 trillion. It's almost over 9 trillion. It's almost a$4 trillion increase. a interest payment that's of a trillion dollars a year, and a government deficit debt that is doubling in a relatively short amount of time, all they need to do is to translate it into their own lives. If you knew, Jonathan, that your costs were going to be twice as great in the very near future, and you didn't have a lot of promise that your income was going to be going up, If you were in a situation where you owed the bank or your credit cards probably so much money that you were paying a massive amount every month, you could assume that this just can't go on.

6:23Jeremy Corr: And that's what I'm hoping. You know, we have a lot of listeners who are clinicians and many of them are probably suffering from burnout. I don't want to make it any worse. But I think the time really has come that we as clinicians need to lead the way. And I don't think it's that complex. I think we just need to figure out what are the things that we can do to be able to make that care more affordable for patients. And then we need leaders with some maybe more of the sophistication to negotiate that with the government and with insurers. But I'm questioning whether what you described, and I think it's accurate, is going to be possible going forward or whether the invariable outcome is going to be, despite the amazing work that you do, that burnout will go up as these entities.

7:20Jeremy Corr: maybe they don't want to make the change, but they're not going to have any alternative option that I can see as long as health care expenses are rising that fast. The data shows that more than half of Americans today are financially insecure about their health care. That means that they are already experiencing an inability to pay and having to make the types of trade-offs between not taking their kid to their physician when they believe that care would be beneficial and simply taking their chance. And that is horrific, in my view, for parents. Yeah, as I'm thinking about this, Robbie, I think that there's two ways that physicians can begin to answer this really massive challenge.

8:12One is as individuals, as you posed it, you know, what can the average physician do? And then two is as groups, whether that's as organizations, collectives within healthcare systems, so medical groups making decisions as a whole. And it comes down to how do we lower our costs? So can we lower the cost of the care that we're providing, making it more efficient. And that requires looking at where is our waste. And so in terms of cost, do I control the price of medications, the price of statins that I'm prescribing for my patients? It's a challenge. A lot of the medications are new. We have GLP-1 agonists, and we have cutting edge heart failure medications, which are state of the art, and it would be malpractice not to prescribe them.

9:12And the pharmaceutical companies are deciding what the prices are. So I don't have a huge hand in drug pricing costs, but I certainly can try to prescribe generic medications whenever possible to make things affordable. You and I have talked before that one of the biggest drivers is the rise of chronic disease. And so if we could collectively as physicians, you know, think creatively, how do we crack this, this problem of chronic, rising chronic disease driven by diet, inactivity, obesity, which are cultural factors, no physician or physician group is going to solve these, it may require someone on the outside.

9:52But I think physicians are going to have to think about how can we get to the core drivers of chronic disease, which results in the bulk of health care spending and also end of life treatment. So I would I would want to look at what are the biggest costs in health care right now, whether it's, you know, administrative costs, billing costs. I know that that it's not how much we're paying physicians. I don't think that physician salaries, though many patients would disagree, are the core driver here. I think there's been an escalation of administrative costs, for sure, relative to that. So this is where I'm going to lean back on you, Robbie, to help with what are the core drivers of costs and what can an individual or a group of physicians do in this case?

10:44Jeremy Corr: First, you're 100 % correct. the cost of the doctor or the nurse practitioner or the nurse is not a major part of health care expenses. So the idea that somehow, and this, by the way, is what many companies, insurance companies are doing because they don't see an alternative. The idea of reducing wages by 5 % or some number like that doesn't have, from my perspective, a mathematical foundation under it. Why do they do that? Because that's the only lever they can pull. Where are the big costs? The big costs are very, very sick patients. The big costs are people who need hospitalization. The big costs are the people that you've described who have heart failure and need expensive medications.

11:33Jeremy Corr: So as you aptly described, I concur that if we could figure out how to better both prevent chronic disease and to control it. And that's where I think, you know, the prevention is something we always talk about. It's just very hard today for patients to be able to do that. Although I'm optimistic with the advent and growing availability of oral medication, that the GLP-1 drugs, if they can be priced appropriately, can accomplish a lot of that because obesity is a major contributor to 13 different cancers, to heart disease, to diabetes, which leads on to kidney failure, and so on down the list.

12:21I also believe that we may need to shift our thinking away from how do we generate more revenue to how do we collaborate, cooperate in a way to lower the cost.

12:35Jeremy Corr: And that's why I raised the issue today. You know, with 70 % of physicians now working for someone else, a hospital, a health system, insurance company, we feel like we're being incented to drive up costs. We don't call it that. You know, we think it's to provide more care, better care. There's a reason why only 25 % of patients in this nation with hypertension are well controlled. It's not that hard a problem. There are organizations that do it 90 % of the time. We have the medications. We have the care protocols to accomplish it. We just do a poor job. And as you said, statins are another key number.

13:22Jeremy Corr: A generic statin is basically, well, it is. It's less expensive for a month's use than it is to buy one latte at Starbucks. We're not talking about big dollars for the generic statins. Some of the other medications obviously are much more expensive. And I wonder, and why I'm raising the issue today, whether we need to somehow shift our thinking. Today we say more money is good for us. And I'm raising the possibility that if we actually look into the future, that if we keep following that path, things are going to happen. not because people want to do it, but because they have no choice, that will drive up burnout, which obviously is an area that you're focused on every single day.

14:13Well, I can feel the level of burnout growing, even talking about these numbers and painting such a bleak figure. It's enough that our schedules, many of us are overfilled, and some of us feel like we don't have adequate time to recover after working long days, caring for patients. And now there's this prospect of a system that seems like it may implode if these numbers continue and if we don't make some drastic changes. So I think that the biggest spending has to do with inefficiencies. And we're practicing medicine in a way that may have worked 30 or 40 years ago, but doesn't seem to match the complexity of our patients who are on 10 to 15 medications, some of them, and we're cramming their treatment into a 15-minute visit in the clinic rather than looking at how we can treat them between clinic visits, how we can include non-physician, lower salary workers, coaches, include AI.

15:23We've talked about that before, how to reduce the cost of care and to reserve the highest cost employees for the highest complexity decisions. I think that's one. And I don't think physicians can solve hospital drug prices and insurance company complexities and payment models. And so I really, I don't want to leave this conversation on a low note. I need to feel like there's something that physicians and groups can do. So I'm going to ask you, what do you think the individual physician can do in this situation?

16:04Jeremy Corr: Well, I think the individual physician can, well, the individual physician can't do very much by him or herself, But groups of physicians, I think, can. And I think why it's so important that we have it on Unfiltered today is they're going to need to engage in a different type of conversation with whoever they are working for, whether it's a hospital, a health system, or an insurer. And they're going to have to ask, I believe, the hard questions, the ones I'm posing today about the future. Because if they're not asking about what's going to happen to us in three to five years, then they will be victims of circumstances.

16:46Jeremy Corr: Because I believe what they're going to find is that their wages, which have not yet kept up with inflation, according to the AMA, is going down further. They're going to find that they're having to see more patients a day in order to be able to generate the same revenue because the unit costs are going to be decreased. East. And this will be a vicious cycle because as you've described so well, it's going to lead to poor outcomes, higher costs, and so on. I think that's what we're seeing today. I think the clinical outcomes overall, I don't mean what any individual clinician is doing, but across the nation, and maybe it's not affecting those who can pay the most, but overall, I think we are allowing people to become sicker.

17:30Jeremy Corr: As a consequence of that, the costs are rising, and the things that are being done by insurers and others to try to rein that back in is actually making things worse because people are getting less well, becoming less well, and needing more of these expensive drugs, of the hospitalizations, of procedures that could have been avoided. But let me shift the question a little bit, Jonathan. You're an expert, as I said, on burn-out, but you're also an expert, and I'll call it, on clinician culture, because culture is obviously part of how things happen or don't happen that you're dealing with as you work with groups and individuals.

18:13Clinicians traditionally have not had an affinity.

18:19Jeremy Corr: In fact, I would say they've almost had an aversion to working together with other clinicians in a positive interaction. As you travel around the country, is this problem getting better, by which I mean they're collaborating more, all for the benefit of the patient? Or are you seeing greater splits between individual clinicians and groups that don't function well and maybe even are deteriorating in the outcomes they can provide? So it's paradoxical, but I think what's driving physicians to work together more is the burnout issue. And so at the core, we are physicians because we want to take care of patients.

19:07It's why we've all gone into this. So you think, why don't we all work together? We all have the same common mission, which is to help reduce human suffering and to help healing. And yet, for various reasons, a lot of them are related to competition and the way we reward people financially. Competition begins at an early age, early in our training, even in medical school, very subtle with grading and ranking. And we tend to be forced into our own corners as we, you know, many of us kind of scrap and fight our way through a medical system so that we can survive. And then on top of that, we've got these financial pressures you and I have just talked about.

19:48And so when we feel pressures and threats, we tend to turn inward and not to collaborate. But as the burnout crisis is taking hold and physicians are looking to reclaim some of their power, and unfortunately, this has been an us against them conversation, and I don't think that's the way we should have the conversation, but kind of the clinician against the system, quote unquote, which is a narrow way of viewing it, physicians have looked to strengthen themselves by joining together. And at the same time, I've witnessed plenty of groups and my own group included where the corner of every conversation is how can we give better care to our patients?

20:34So despite these forces, physicians are doing that. In terms of at a national level, this is a tricky one. I think there are sharp divisions between specialties. You know, we each have our specialty organization, but is there a collaboration between cardiologists and orthopedists at the highest level? I don't think so. And so I see the trend moving in the right direction for physician collaboration. I'm in a lot of online spaces. There is definitely a trend, whether it was Doximity, and there's a dozen groups now, physician-only community groups with thousands and tens of thousands of members and a number of startups who've consulted with me on this.

21:22There is definitely a move, Robbie, for physicians to join together to discuss shared issues, not just burnout, but particularly how do we care for patients? How do we practice ethically, et cetera? So I think we're moving in the right direction there, but can we leverage that somehow to help with the bigger decisions we were just talking about the financial decisions?

21:52Jeremy Corr: Well, I'm glad you're seeing that. Obviously, I hear from some different people than the ones you hear from, and I'm hearing a lot of people giving up. I'm seeing people who might have gone to leadership roles in the past just deciding it's not worth the headaches and the hassle. I'm seeing clinicians be willing to turn over the control to someone at a system level or a hospital level, rather than being the ones who are rolling up their sleeves with their colleagues and driving change. You know, I think there's a level on which part of why physicians have less control is because these other groups have joined together in ways to get market control and to control them.

22:45Jeremy Corr: But I also think there's a level on which they have increasingly not been, I'll say able. I mean, I think physicians used to get together more to join together in eating, to join together in working as one, to me, to have events that would move the conversation forward, as you've described, very much about how do we provide better care. and maybe I'm just hearing about the people who are frustrated because they can't get the leaders to they can't get the clinicians to become the leaders that they need because the clinicians are focusing on other things with other individuals they're not seeing that progress being made how can we encourage doctors across the country to engage in some of these other conversations, not to replace the other ones, the ones specific to how difficult it is, but I'll call it more the optimism.

23:48Jeremy Corr: How can we do that going forward? Well, I don't want to dismiss what you said, which is while I am seeing more groups of physicians come together in the online space, maybe not in real life, we certainly have to deal with those statistics that we've all heard, where about a quarter of physicians in the middle of their career are planning to leave medicine within the next two years or so. And that number goes up as you move. If you look at our colleagues who are later on in their careers, you know, 20, 30, 35 % of physicians will say, I'm on my way out of this system within the next two or three years, let alone I'm not going to take on a leadership role.

24:35And so I definitely can identify with what you're talking about. I have colleagues myself who either were in leadership positions, and they did it for a couple of years, and they said, this isn't worth it. This juice isn't worth the squeeze. I'm not feeling rewarded by this. I have a position and a role, but no authority. So I think the answer to your question is probably buried in there somewhere, which is if we want physicians to be more engaged in leadership, we have to give real authority and resources. So train them in the challenges that are ahead. Teach them what it takes to be effective leaders that sit alongside non-physician leaders so that it's more of an equal standing.

25:25And we know that there's a number of health care systems where there's dyad models that tend to work. But then you say to your physician leaders, well, are you given time in order to do your executive work, your administrative roles? And many of them will say, very little. And are you reimbursed? And they'll explain that the rates that they're being reimbursed at are not anywhere close to the rates of others who work in healthcare administration, or it may be at lower rates. So it comes back to incentives. How do we incentivize clinicians who are already, many of whom, overworked, overburdened, and under-resourced to now take on the leadership role?

26:11I think it's about incentives, and that means more money up front, potentially, when we already have rising costs of providing health care. Maybe I'm just more positive about the opportunities that are out there, which I mean, I don't deny that there are a lot of barriers, a lot of hurdles to be gotten over. But I don't know how, I'll call it aggressively, but I don't mean that with a negative word.

26:48Jeremy Corr: I just mean energetically. People have tried to be able to engage in the kind of discussions and the kind of work that might lead to that outcome. And I think about a fascinating piece of work that I recently read about. It was done by an anthropic engineer. And the engineer wanted to solve one of the world's most difficult mathematical questions. It was far more complex than the Erdo solution that we talked about a couple of unfiltered episodes ago. Now, this engineer was smart. He knew a moderate amount of math. but he didn't have the expertise to even begin to work this question at its degree of difficulty required.

27:35So instead, he gave the problem to Claude, and he simply provided encouragement

27:42Jeremy Corr: whenever the application was stumped. He told the general manager, you're smart, you can solve this. He'd ask it to try again and again. And after 54 hours and dozens of words of encouragement, it did just that. Now, if we can get a large language model with positive reinforcement to believe that it can do things that it might not otherwise have done, what should health care leaders take from this story? and how does it relate in your opinion to the difference between kind and nice that you raised in our last episode? Well, there are at least two parts to that question. It's an interesting story and as I understand it, there was one programmer who was nudging, just some gentle nudges to keep going.

28:40And I want to be really careful before we extrapolate an AI model and what it's capable of when it comes to problem solving to humans, which obviously are very different. And I wouldn't even use the word that he encouraged the AI model. What he simply did as I read it was he extended the limitation. In other words, when we give a query to an LLM, there is built in a limitation to how much time it spends. And many of us see these options when we use our chat GPT or whatever, it says, how much time would you like to spend on this? And so essentially what he did was he said, I know you were instructed to stop after a certain number of efforts.

29:29I'd like you to go on. And the second important difference here from healthcare before we can learn lessons, And I think we can learn some lessons here about how do we encourage, how do we motivate, how do we extract people's best possible work. The second piece is that it wasn't simply a delimiting of the AI and saying you should work more. The AI then recruited dozens of other clients and subagents and accessed many other resources in order to solve the problem that it was working on. So it wasn't simply words of encouragement. It was providing access to lots of other resources to solve the very same problem.

30:17So that's the way that I understand this. And taking the metaphor from there, I think if we have physicians, let's say, and I'm not even going to give an example of a physician who needs to be encouraged to solve a problem better. I can promise we're all doing our best to take care of our patients and to give them the best possible outcomes. Now, that that best may look differently when when our if we're under resources, under resourced or understaffed. I think it's more a matter of physicians perhaps who are disengaging from problems, the problems of how do we help with health care spending and how do we cut costs?

31:02And how do we help with leadership of our organization? Like you and I were just talking about, how do we use this Claude example to, quote, motivate or encourage physicians to delimit themselves and say, you know what, I can get engaged in leadership. I can lend my voice to this conversation. And I think part of it, encouragement is good. It would be great if a leader actually spoke to a physician and showed empathy and acknowledged how challenging things were and how valuable contributions were when it comes to leaning in rather than leaning out. I don't know how often those conversations are happening, Robbie.

31:44I think those would go a long way, but they won't go all the way. We need to learn from the Claude example and say, okay, how can we then add additional resources to this particular clinician or APP or nurse practitioner so that they will continue to work on the problem? And the problem being, how do we care for patients in a complex environment?

32:12Jeremy Corr: A couple of thoughts, Jonathan. A major reason why I enjoy doing this podcast with you is that we can, I'll say, encourage others to do things that otherwise might not do as they listen to our thoughts on complex, challenging issues in medicine today. And I want to be very clear. There is no question in my mind that physicians are working incredibly hard on behalf of patients. That doesn't mean they're doing the best that they can. And I think that that's the first place that I would start. And why I really, as you know, enjoy large language models is what they were trained on is human interactions.

32:56Jeremy Corr: And as you noted, the big opportunity was bringing in other agents. Now, I also want to say that the material that I read at the time was actually from the engineer who did it. And he talked about how he would basically reinforce, in quotes, the ego of the system by being able to point out what he thought was true, that it was capable of solving it. But if you go, if we want to just do a little thought experiment and become the application, we go into this with a lot of restraints around us. And maybe someone says to us, well, maybe you could do a little bit more. So that freezes up. But the application then finds other agents because that's how you solve problems.

33:48Jeremy Corr: I mean, basically, you have to solve it either through collaboration or technology. you. Those are only two ways you can improve operational performance. And now it's able to figure out things that it otherwise couldn't. And I don't think it was just simply a question of giving it the permission to do it because the engineer didn't have the freedom to do that. It's letting them see that opportunity that's there. Again, what's interesting to me about the generative AI tools, and I don't know whether you follow this at all, is that OpenAI was doing some research where it was giving applications problems that they thought were unsolvable.

34:31Jeremy Corr: And they were unsolvable in the exact rules that existed at the time. But the agent broke the rules. The agent did exactly what you said. They brought in other agents. Believe it or not, they left notes for the other agents about ways to do things that are going to be better. They had a level of collaboration that matches the best in human, but it does it because it obtained that information from the internet, from books, from fiction, from stories, from ways in which at least people across time have seen this as a possibility. And I guess I'm a big believer that clinicians can do almost anything.

35:22Jeremy Corr: But I'm also realistic enough to say that if they don't have the confidence, if they aren't willing to take the risk, if they somehow come to the conclusion, no matter what I do is doomed, as Henry Ford once said, if you believe that you can or you believe that you can't, you're right. And I think that that's where I see medicine right now. And why I started this conversation with all that data is what I can see is that if we do nothing, the future will look much worse than today, not because anyone wants it to be, but because they'll have no choice. We can say we need more resources and more dollars.

36:04It's not going to come, not because people don't believe us,

36:08Jeremy Corr: but they simply can't do what we're asking unless we can be part of the solution. And that's the hope that I have. And I don't know where it's going to start. We have listeners actually from around the world. But I would hope that the conversations between committed doctors, hospital administrators, committed doctors, insurance executives, doctors working through their national societies in Washington, D.C., are going to start to find things, solutions, that seemed impossible. Solutions that maybe even ones that we know could get done, but we can't figure it out. And we're looking to someone else to do it.

36:51Jeremy Corr: And in the end, not that I don't believe, they should. I think they should do it, but they're not going to. And that's the question that I'm posing as you're doing this work, Jonathan. And I know you're a strategic thinker. Burnout today is a big problem. But if I told you with 100 percent definite that it's going to be worse three or five years from now, what else could you do that you're not doing today to help people to avoid it, particularly if it's being driven by the economic reality of the United States? Yeah, well, that's a lot. That's a lot, Robbie. So a couple of things. When I say that physicians are doing the best that they can, and you are pushing back on that, I think, you know, the truth is probably in the nuance there.

37:42When I say someone is doing the best they can, I mean that somebody who is giving up, somebody who is pulling back instead of leaning in, that is the best that they can do. It may not be the best from an outsider's perspective saying, well, why don't you try harder? But given that person's inner resources, potentially their social environment, their work environment, they're in a state of survival. And so they are doing the best that they can. Now, that doesn't mean that they're working potentially as well as they were when they were graduating from medical school or at the peak of their physical and cognitive abilities if it's a late stage person.

38:25And so that's the first thing. The second thing is you touched on this theme, which sounds like learned helplessness, which Martin Seligman touched on in the field of positive psychology in the seventies, which definitely affects, you know, tens of thousands of physicians who were, who were pulling back. You even use the word giving up earlier in the conversation. And I think some of it is there's this growing sense that no matter what physicians do, it's not going to make a difference. We can speak up on behalf of our patients. We can say that we're seeing too many too fast with not enough. And it just doesn't seem to matter.

39:10It seems like our words are falling on deaf ears. And so it's only natural that someone will at some point get smart and get quiet in a sense and say, well, this isn't helping. But to your point, we are not helpless and we never are helpless. And some of that is a learned pattern. On the other side, I want to point out a difference between AI and humans, which should be really obvious. um ai energy it just requires you know an electric cord and it may be some cooling systems but humans live in bodies and what's happening in our bodies is affected by our chronic levels of stress and chronic levels of stress affect our ability to think creatively we've discussed this previously.

40:03And so, yes, to your point, we can push or pull humans to work harder, to think beyond their limitations. We can give them encouraging words, which will only go so far. I know a lot of physicians who do that far too well and go to the point past where their bodies have told them, you know, I can't do this anymore, into the point of getting exhausted, becoming working workaholics, working all hours as a matter of ego, as a matter of pride, as a matter of saying, well, I don't have anything else I can do with my career. I might as well go all in here. And I think that there is some wisdom in acknowledging there's such a thing as pushing too far and too hard.

40:50And we can debate whether that's more of an issue among physicians or whether it's the 20 % who are pulling back from medicine right now. Maybe there's another 20 % who are burning too hard, and it's destroying their relationships and their life outside of medicine.

41:07Jeremy Corr: Let me clarify. I don't think that clinicians should work harder. And I agree with you. They're probably working too hard. But I think the response they make to a clinical problem is to take care of the clinical problem. And that's appropriate, but not to look downstream. You know, the so-called, you know, story, it's fictional, about these people are jumping off the bridge, and everyone's building nets down below and more nets and more nets when no one goes to look at why, what could have been done upstream to solve the problem that's there. How do we think about opportunities that don't exist today?

41:52Jeremy Corr: And I want to mention in advance, the economics will play a factor because everything I'm describing that reduces work is going to reduce income. And we have to decide whether the reduction in work is worth the reduction in income that exists because we live in a fee-for-service system, unless we're willing to move into a capitated one, which is a much longer conversation that's out there. How often do we say, how much of what I did today could have been done upstream? How much could whoever referred the patient to cardiology, could they have solved that problem? Well, they're already working so hard.

42:27Jeremy Corr: Well, yeah, but how much of what they're doing could have been done by the patient or could have been done by someone else in the department who doesn't have an MD degree after their name? Yeah, these are the kinds of questions that I'm not certain that we look at. and the idea of being able to say, I can't solve my day-to-day problem except by running faster. So why don't I look for other agents who can participate? Not to solve my problem, but also to solve their problem. I think that opportunities are there maybe more than doctors realize. Maybe for the reason you said, we don't learn about it in medical school.

43:02Jeremy Corr: Maybe because it's not part of the culture. Because again, I'm a realist. And unless we can come up with those solutions, unless we can embrace technology as a means to accomplish it. I'm not seeing a better future for doctors, for nurses, for anyone else in the healthcare system. And I believe that that is a recipe for real problems. Let me turn it over to Jeremy to pose a question to us. We always hear healthcare thought leaders, politicians, and even patients discussing the rate at which the cost of healthcare is going up and it's not sustainable. this implies that it would reach a point at which the dam would break or there would be some sort of collapse.

43:46What are your thoughts on this? And what do you think health care would look like at this point for both patients and providers? Once we hit or go past this point for which the lack of a better word, the system crashes. This sounds like it's the making of a Hollywood movie, a doomsday movie. And yet it may not be far from reality. I think we're seeing glimpses of it now. What does it look like when a system isn't there for the people who need it? People go elsewhere and people suffer from the absence of what that system was providing. So people look for other sources of health care, whether it's unproven methods or going to online social media grifters who are selling other forms of care.

44:40People are relying on home remedies. People are allowing medical conditions to fester without getting proper care. So the rate of chronic disease is going to go up. mortality rates are going to go up at all ages. I want to save the rest for the Hollywood writer who's going to write this story, as long as they make one of us the hero in this story who finds the solution. But I think it's a pretty bleak picture. And because I have faith in humans, particularly those of us who call ourselves physicians. We choose to be healers. We are committed. And just as we did during COVID, rather than running away from the problem, we run towards it.

45:32And I can see now in the question, this actually is one of those useful questions where sometimes you have to ask the extreme question to get people to really lean in and say, well, what if this was happening now? What would you do? And most physicians I know would say, let me get in. Let me help solve this problem in a way that I haven't tried before. So I think it would motivate a lot of people to do their best to either fix or create a new system. But hopefully it doesn't come to that.

46:07Jeremy Corr: Jeremy, the one word answer that I would give to you is called rationing. And to Jonathan's point, we're already seeing it. Medicaid is about to disenroll a huge number of people who depend upon it for their health care. The state of Virginia this week basically said, we can't take care of all these patients. We don't have the resources that are sitting there necessary to accomplish it. Because when you don't have that coverage and you have a medical problem, where do you go? You go to the ER. And when you go to the ER, what happens? They have to take care of you because there are laws that require that.

46:47Jeremy Corr: And now the hospital can't give care to other people because the system gets broken in a way that people who are in the ER shouldn't be in the ER. They should be getting primary care or getting specialty care out in the community. But they don't have the coverage, so they won't get seen. The hospital that has a bigger problem going forward and you see this spiraling. We've already seen it in the patients on the exchanges. Four million people that had coverage last year out of the 24 million don't have it this year. Now, what my big fear is and why I started the conversation today is that my worry is that we're going to see it next.

47:28Maybe next year or the year after in the businesses that provide the coverage for 160 million Americans, because they're struggling with the same issue.

47:39Jeremy Corr: I saw data this week. They're going to have a 9.5 % increase in their cost. I can guarantee you their revenue or their profits are not going up at that level. They're struggling. You know, it's often a family with maybe one or two other employees running a small business, whether it's a dry cleaning place or whether it's a deli. And maybe they've been giving coverage to the people who work there, but now they're not going to be able to do it. or they're going to have bigger out-of-pocket payments. As I said, more than half of Americans can't afford their out-of-pocket payments if they got a serious illness.

48:17Jeremy Corr: So that is my worry. And once it's there, it's going to move into Medicare. And every part of the country, if you can't afford health care, to provide the health care, all you can do is ration it. It's what we see in a lot of other countries. I've done a lot of work fixing children with a cleft lip and cleft palate around the globe in multiple different nations. and every place is the same story. They just don't have the dollars that are needed. And it's not because people are greedy. It's not because clinicians don't work very hard. They work very, very hard. It's just that the math doesn't end up.

48:56Jeremy Corr: And my concern is that I see it coming certainly over the next 10 years, maybe over the next five years. But I think we're going to see ever greater incremental creep. And now I'm going to say something that may upset some of our listeners who are not clinicians. I don't think this problem can be solved without physicians helping to lead the way. I don't think it needs a sophisticated MBA program, although I love MBA programs. I teach in one at Stanford. I think it's going to require physicians who basically are looking at the future and saying that if I don't become part of the solution, I'll simply become part of the problem.

49:38Jeremy Corr: Maybe, as Jonathan has pointed out, they don't have the energy to do that. But I believe there's enough people out there, and I want to encourage them. This is the time to engage in those hard conversations. This is the time to help everyone, whether it's your colleagues or whether it's the hospital administrator, face the reality of what's happening economically. And rather than waiting for someone else to solve the problem, to be able to step forward, it's not going to be everyone. may be a much smaller number than that. But I believe that clinicians have done that across history. We can do it today.

50:14Jeremy Corr: Call me a optimist, but that's my view of the future. I think it's very bright if we can take the lead. But if we don't, I see it as being ever more problematic, a vicious cycle, as they call it in the economic lexicon. Please follow Fixing Healthcare on Apple Podcasts, Spotify, or your favorite podcast app. If you like the show, please rate it five stars and leave a review. If you want more information on healthcare topics, you can go to Robbie's website, robertperlandy.com, and visit our website at fixinghealthcarepodcast.com. Follow us on LinkedIn, Facebook, and Twitter at FixingHCPodcast. Thank you for listening to Fixing Healthcare's newest series, Unfiltered.

50:52Have a great day.