What It Takes to Fix a Broken Healthcare System with Erin Nance

0:00To replace these systems with no systems and with no funding is not the answer. For bedrock systems of the American healthcare system, you don't throw the baby out with the bathwater, right? But unfortunately, misinformation seems to be in the eye of the beholder. And we have lost sense of what are the medical truths and what are the medical facts. Hello, everybody. It's Guy Kawasaki. This is the Remarkable People podcast, and this is the first episode I'm recording from Hawaii in an apartment we just took. You may hear a little bit of echo because I haven't quite figured out the acoustics of this room, but I couldn't wait to interview our remarkable person today.

0:55Her name is Erin Nance, and she is a remarkable orthopedic surgeon from New York. and to put it mildly, she is literally the person you want when you need a hand, shall I say. She is like world-class orthopedic skill. She's a writer. I loved her book and if any of you are considering the medical profession, you have to read the book. It's called Little Misdiagnosis and we'll get into that and she's also championing women in medicine and women health care. So So welcome to the show, Erin Nance. Oh, thank you so much, Guy. And I have a confession. I am feeling extra remarkable because I am wearing the socks that you sent me.

1:42So I really feel extra remarkable today. We'll send you more. You can feel remarkable every day. You sent one for my husband as well, which is much appreciated. Don't you have kids too? And I have a little one. How old? She's 10. Not so little anymore. Oh, no. People told me this when I first had kids and I said, no, you're making stuff up. And they said, you're going to have your first kid. You're going to blink and he's going to be going to college. And it's absolutely true. It's absolutely true. Yeah, yeah. So first, I've dug into your dark past and I have figured out that you are zero for four with Stanford.

2:28So Stanford is so stupid. They rejected you four times. Yes, I self-proclaim have the highest rejection rate from Stanford. I hold the world record for being rejected from Stanford. I was rejected for college, for medical school, for residency, for fellowship. Stanford really doesn't want me. But I really wanted to go to Stanford. My whole life, when I was a little girl, I was a very big swimmer. And at the time, all of the Olympic swimmers went to Stanford, right? Summer Sanders, Janet Evans, Jenny Thompson, they were the gold standard. So I said, I want to go to Stanford. And my whole life, it wasn't as if I thought I was so smart and everything would go my way, but I just never considered any other school.

3:22And I'll never forget that when I was in high school, the admissions counselor from Stanford came to New York City and did a talk for all of the prospective parents and the applicants. And I remember at the end of the talk, these four girls from Chapin, which is another school in New York City, them and their parents went up to the counselor and they were all giving each other hugs and kisses. and for the first time I thought, maybe this isn't going to go my way. And lo and behold, I was rejected. I was so in shock. I called them to make sure that it wasn't a mistake because it had to have been a mistake, right?

4:06There had to have been some grave mistake. And I said, oh, I guess I'm on the wait list. And they go, no, you're not even on the wait list. They're just rejected. So yeah, Stanford really was my first heartbreak. But it taught me that a heartbreak is there for a reason, right? It wouldn't hurt if it didn't matter so much. And really, that laid the foundation for me building this resilient path. And when you zig, you got to zag. I am slightly better with Stanford. I'm one for two. I got in as an undergrad. I got rejected by their business school. And lo and behold, when I was an undergrad, I thought I wanted to be a doctor.

4:52So I was pre-med and I enrolled in this class that you go on rounds at the medical center. And the first day of that class, I fainted. And that's when I decided I'm not going to be a doctor. So I wasted your bullet. I wasted your silver bullet. I feel terrible to this day. Oh, my God. No, there's a reason why I like people who have that experience to know that they're not supposed to be doctors, right? It's part of the pathway. And I think anyone who has really any advanced exposure to healthcare is so helpful because you can be a champion for healthcare in so many ways besides being a doctor.

5:33I just want to express my empathy. I read your book and I've seen your videos and the story you tell about the first day that your residency started and you get this call from your mom and your brother that your other brother dove into a pool and got paralyzed. Wow, what a story. So how is Kevin now? Kevin is doing absolutely incredible. He is married. He has a beautiful daughter. He works for a bank. He is a fully functioning member of society. And I will say this about Kevin, is that he is a better person as a result of his accident. And again, the resiliency and the determination and grit that he shows.

6:23He's an inspiration to everyone in the family. And certainly for anyone who has newly been injured, his incident was he dove into a pool that had that kind of slant between deep and shallow and he hit it straight on, instantly paralyzed. Although I just got off the phone with him a couple of days ago because we had a speaker from Johns Hopkins come to the New York Society for Surgery of the Hand. We have a quarterly meeting and we invite all the latest researchers. and he was talking about the latest research for nerve transfers for quadriplegics. And there has not been any innovation for quadriplegics in decades.

7:08Neuralink, what Elon Musk is doing is something totally separate, but in terms of things that are actively, you can actively get this intervention. And so we spent all night reading the papers from this doctor and trying to see, because he has never given up hope that he will recover 100%. I don't know if you've heard of him, but one of our past guests was a doctor named Jerry Silver. And he unfortunately passed away. But Jerry Silver has pioneered this work in using peptides. And the company is called NerveGen out of Vancouver, Canada. And right now, you don't inject these peptides into the spinal cord.

7:52You inject it subcutaneously. And it inhibits, and I've got to read this so I get this right, it inhibits the protein

8:04tyrosine photophatase sigma. I don't know what any of that means. So yeah, we've had a guest talk about the recovery of people with spinal injuries. Yes, and to be honest. Even myself as an orthopedic surgeon, I was unaware of what the potential recovery could even be. And I learned so much. I write in the book that Kevin became my first patient. And I remember clear as day, and I write about this. We were just sitting outside. He was in his wheelchair. And I could have swore I saw his toe flicker. And I said, Kevin, I go, did you see that? Did you feel that? And he kind of hesitated and he said, I didn't want to admit it to myself if it was true because if it wasn't, I would be so devastated.

8:59And that was the beginning of some recovery for him. He's able to even walk. I wouldn't say it's functional walking, but it's enough so that he is able to at least relieve some pressure and get a little bit more kind of exercise. But yeah, I did not know what was possible. I just thought you were completely paralyzed and that was it. I'm going to jump around to all kinds of different subjects. This is not a linear NPR kind of podcast. We go all over the place. So now I want to ask you a very deep and personal question. So when you broke your arm as a little girl, or actually you didn't break your arm, you bent your arm, and your father's friend shows up in the ER to treat you and he's wearing a tux.

9:49So is that the moment you decided to simply become a doctor or to become an orthopedic doctor? Oh, I wanted to be him. I think on the end of second grade, you had to draw a picture of what you wanted to be. And I wrote, I want to be an orthopedic surgeon. Okay, not doctor. I wanted to be an orthopedic surgeon. In my eighth grade yearbook, I wrote, I want to be the orthopedic surgeon that takes care of the Mets, the Knicks, and the Rangers. And I ended up achieving that. I did my fellowship at Hospital for special surgery. I took care of, we were the team doctor for the Mets. I treated many different players from the NFL, from the NBA, every sport, you name it, we took care of them.

10:36So yeah, it is a bit rare that you know so specifically at such a young age, what you want to do. And I tell people when they ask, how did you do that? I say, it's a mix of determination and stubbornness, right? I had already put it out there that I was going to be this orthopedic surgeon. And it would be pretty embarrassing if I came up short since I just kept saying over and over and over again. But yeah, it's a little bit of manifesting, but it's a little bit of just staying the course. So you're saying that you were an orthopedic surgeon for all these professional sports and stuff. So if we are not violating HIPAA, can you tell us who's the most valuable hand you ever worked on?

11:23That is a great question. So I will say I have worked with many different categories of people whose hands are super valuable. So I have worked on musicians whose hands are insured for millions of dollars. I have worked on NFL wide receivers who are in the Hall of Fame. I have worked on NYFD firefighters who their hands are their livelihood. I have worked on politicians who use that pen to write orders. So, yes, I will say working at HSS is probably if you were a paparazzi, don't waste your time on Hollywood Boulevard, go stand outside of the waiting room at HSS. That is the hottest ticket in town.

12:20I have, I think what's called digital mucus cyst. So if I remember in New York, could you just remove it for me? Oh, I know what we can do. When you're in Hawaii, bring your scalpel and you can just cut it and I'll take you out to dinner. How's that? You know, mucous cysts, so here's an interesting topic. This is something that is probably a hand surgeon's least favorite topic to treat. Why? Because the mucous cyst itself is not a problem. It's really a sign of underlying arthritis. So the issue is that the mucous cyst isn't an issue, except that it is ugly, right? It's ugly looking. And so the patients come in and they say, hey, especially, listen, I'm New York City.

13:10We have our Park Avenue ladies. They don't like how that looks. But the issue is that the skin is so delicate that when we do a procedure to remove it, you're at great risk for infection, for developing wound healing issues. So the only time we recommend removing it is when there is an underlying infection. We don't remove it for purely cosmetic reasons, which gets everybody in a tizzy because that's why they came for it in the first place. But yes, I would say that is probably a difference from my background being an orthopedic hand surgeon versus a plastic hand surgeon who may be willing to do things for different reasons.

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14:41Today, Raz's success is proof that with passion and the right support, it's possible to make your dreams a reality. Learn more at CapitalOne.com slash business cards. You're listening to Remarkable People with Guy Kawasaki. You know what? When I knew I was going to interview you, I started reading about orthopedic hand surgery and all this kind of stuff. And I said, I wonder what this thing is on my finger. And then I did that. And then it says, the first thing they recommend is never drain it, never try to take it off, which I have done multiple times, of course. I am convicted. Now we're going to jump back to your book.

15:21And again, I just want to say, if anybody out there is thinking of being a doctor or knows somebody who's thinking of being, you have got to read this book. Just the first chapter alone, when you describe what you have to go through to be a doctor, my God. So as I was reading your book, I asked, you know, is all the crap starting from your college degree to residency to all this stuff that they put you through. Do you with hindsight look back and say that is good that it was so hard it was so challenging it really separates the people who really want to be doctors from those who are pretenders or do you say that that was needlessly traumatic and we would have just as good doctors if we didn't try to beat the crap out of them to get their MD?

16:14Well, I'll answer it this way. When I was a PGY3, the 80-hour workweek went into effect. Now, if you know a little bit about the history of what the 80-hour workweek is or what it entails, it was started because there was a reporter, I believe he was from like the New York Times or a prominent New York magazine. His daughter died in a New York City hospital because he felt that she had a medical error made by a resident who was overworked, right? They had been working 36 hours straight or whatnot. So they pushed to make a law that no resident could work more than 80 hours a week. Now that was technically in place, but it was never enforced.

17:03So when I was the PGY2, the junior resident, I was working 36 hours straight. I was working 100 plus hours a week. I was always known for having this iron bladder because I could go an entire shift without going to the bathroom. And people said, how could you do that? And I go, if you don't drink any water for the whole day, you don't have to go to the bathroom. Now I would come home after that shift And my lips would be cracked and bloody and I would pass out on that bed and not wake up. No one could possibly wake me up. Do I wish for my junior residents to go through that? Absolutely not. Absolutely not.

17:52Do I think there is a difference in the level of accountability for patients between my era of trainees and today's era of trainees? Absolutely. Wait, so the conclusion is that the system windows out the people who really should not or do not want to be doctors. So you're saying the system works as it is, or we should change the system to be more humane? I think it has to change to be more humane. Just even getting a good sense of what it's like being an up-and-coming doctor, a resident today, they will not stand for being overworked. They will not stand for not being able to eat or go to the bathroom.

18:41They will not stand for no attention to their mental health and their personal well-being. I mean, I had no personal well-being there. Just that was how the system worked. In my Lenox Hill residency, we only had two residents per year, okay? Which means there were only four junior residents. So that meant for 365 days, right, 24-7, the four of us were, at least one of us was always working. If you can imagine that. Now they'll have a PA take a shift or they'll bring in another resident from a different subspecial to help cover. So I do think it did train me. you know, it was funny, we were talking about trying to coordinate this podcast and you were, our original time was going to be 4.30 a.m.

19:38Hawaii time. And I thought that's really cruel to make you work doctor's hours. But for me, that is not so out of the ordinary. And it's because of that training, right? I wouldn't even blink if you said, hey, we're going to do the podcast at 4.30. I'd be like, cool. It's 4.30 my time. It's 10.30 your time. Exactly. In your book, you describe this very funny scene. I guess it's funny now, but maybe it wasn't funny then. But it seems to me that in house and whatever, ER and all these TV series, there's So always this moment where the surgeon or the doctor in charge is saying, I want you to name the ileolumbar vessels.

20:24And it says, all right, Aaron, what are the three vessels there? And of course, most people don't drop their glasses on the patient, but that's a different story. Now, do those kind of moments really happen where the doctors just say, okay, what are these three vessels? What are these three things? You know, whatever. So that's question number one. Does that really happen in life? And secondly, does it really matter if you didn't know what those three vessels were at that particular moment? Would that make you a bad doctor? So that process is called pimping. Okay. The attending pimps the resident or the resident pimps the med student.

21:07And it's both a process of trying to see if they did their homework, if they prepared, make sure that they are prepared for the case. But it also establishes this pecking order, right? The attending is the one pimping the juniors. And most of the times, it is some esoteric fact that only the attending would ever know the answer. And it just kind of establishes that hierarchy. You know who is the alpha dog and who is it. In some instances, it's used really to create a culture of intimidation, a culture of fear, a culture of anxiety over getting these questions wrong because no one's pimping you in private.

21:52Okay. You are being pimped in public. That is the point of pimping. so I do think it does make sure that you are going to these cases prepared and I'll tell you a story that it actually did not make the cut because it was accidentally left out of the book but there was a day where I was on the joint replacement service I talk about Dr. Rodriguez in the book he He is one of my most revered mentors. He's just an absolutely phenomenal surgeon and person. And I'm on his service doing total hip replacements. And he has a system where it's like a hundred point checklist of, okay, put the scalpel at 10 centimeters this way, then take the bovie and grab this vessel, then take the clamp and at this angle.

22:47And the day before the OR day, my mom called me in. We had a family emergency. I called my chief resident. I said, I am not coming into work today. And I went home and I spent the entire day just with my family, making sure everything was okay. And then the next day, I showed up in the OR and I wasn't holding the scalpel right. I clamped the wrong vessel. I didn't do the Mets the right way. And Dr. Rodriguez took the instruments out of my hand. He said, get out of my OR. You are not prepared. And that was it. And I left. I mean, absolutely embarrassed, ashamed. There was no excuse. He was totally right.

23:37I was not prepared for this case. And it didn't matter that I had this family emergency and there was a good reason why it wasn't prepared, his job was to protect the patient at all costs. And that's part of when you're a resident, you don't even realize how many things the attending is juggling at the same time. But of paramount is the safety of the patient above the learning and educational experience of the resident. I like to think that these systems of pimping and all of the grand rounds and the M &M, it is all in the greater good of preparing us for being as prepared as possible for our patients.

24:22But it was a good reminder so early on in my career that the patient safety always comes first. So now I want you with your hindsight and your superior communication skills, can you just tell us what makes a good doctor? Is it the memorization of the vessels of the ileal lumbar? Is it empathy? Is it communication skills? I mean, when push comes to shove, once you're out of med school, once you're out of residency, once you're out of the 80-hour weeks, what makes a good doctor? Number one is lifelong curiosity. That is by far the most important trait that a doctor can have. And why I say that is because many doctors, right, we learn the most intense period is when we're in medical school and when we're residents, but medicine evolves constantly.

25:20And it really takes a dedication to continued lifelong learning to make sure that you are delivering the best care for the patient that's sitting right in front of you today. So I think number one is curiosity. Number two is you have to have the technical goods, right? I know there's a joke that what do you call the person who had the lowest grade in med school doctor? And that technically, yes, there are levels to our knowledge base and our skill set. But when you are looking for a doctor, if you're getting your knee replaced, you want to see someone who's doing 10 knee replacements a week, right?

26:09When you are getting evaluated for lung cancer, you want to see the doctor who they're seeing lung cancer like all day long. So technical expertise. And then the third thing is actually something that Dr. Collins mentioned on your podcast not too long ago, but humility. And I think it's something that not many doctors are actively thinking about. How can I be a more humble person? I think it comes across in our empathy for our patients. When we can acknowledge to our patients, we don't know everything. When we can acknowledge that, you know what, I'm going to have to do a little bit more research and get back to you.

26:56But right now, we have an epidemic of patients who are not getting the care they need from their physicians. And I believe it's because if a physician does not know what is wrong with the patient within the first 30 seconds, that physician most likely is not going to be the one to help you. What? Say that again. Correct. If you're a physician, And this goes back to a mantra from Dr. Chit Ranawat, who's a very, very famous orthopedic surgeon. But one of his mantras is the eyes only see what the mind knows, right? And each doctor has a limited set of what they are really experts in, right? I'm a hand surgeon, but I'm really just treating carpal tunnel, trigger finger, basal joint, wrist fractures, I'm not really seeing kids with congenital hand deformities, right?

27:55And so if someone comes to me and has a radial club hand, honestly, I am not going to be the right person to help you. And that's when the humility comes in to say, listen, I may not be the right person to help you, but I know that Dr. Scott Kozen at Children's Hospital of Philadelphia is the right person to help you and to really guide them to that person who is going to be the best person to help them. It's good to notice. Yeah, right there. That's the mic drop moment of this podcast that if the doctor you're seeing doesn't know what's wrong in 30 seconds, keep looking. Okay. So speaking of that, now this is a perfect segue.

28:38So, you know, it seems to me you talked about a case where this person had gone to multiple doctors and no one could figure out what was wrong with his hand and multiple operations. And you two could not figure it out. And as he's walking out of the office, you come up with this idea. You ask him, have you been on vacation? He says, yes. This is where he says I went to Florida to go fishing. and then you have this brilliant idea that well we're gonna do a low and steam jensen culture on you and that was kind of a house moment now i have a question here so if today if you took all the reports and all the analysis and the lab stuff and all and you stuck it into ai would ai have said you should try a Lowenstein Jensen culture, because in a sense, it was just lucky that he saw you and you came up with that idea, right?

29:37And so can AI help in this problem because there's too much data? And who knows, maybe you never studied the Lowenstein Jensen culture because you were sick that day in medical school. What happens? So I will tell you that I am the host of a podcast called The Medical Detectives. And we interview patients who have had medical mysteries and misdiagnosis for upwards of 20 years, 40 years, actually, was our last guest. And they have seen hundreds of doctors and they have had hundreds of tests. And we know what their eventual diagnosis is by the end of the show. We have put every guest of ours, all of their symptoms, all of their tests into ChatGPT, and ChatGPT gets the diagnosis every single time.

30:27What? Correct. Literally. Correct. Now, I will say that if I, we are seeing the patient at the end of their journey, right? So we have the benefit of all of the tests and all of the symptoms over time. If that patient who came to see me who had, spoiler alert, they had a bacteria called Mycobacteria marinum, his first symptom was just hand pain. If I just put hand pain into ChatGPT, they're going to give me a differential that's 500 diagnoses long. ChatGPT is only as good as the input that you give it. And that's why physicians are really the best suited to using chat GPT to help solving a patient's diagnosis.

31:14Because I tell people all the time, you know, who are having issues with misdiagnosis and being undiagnosed, I go, put your symptoms into chat GPT and ask it for three differential diagnoses. And then you're going to go to your doctor and say, hey, do you think I could have X, Y, and Z? Because if you don't put Mycobacterium marinum into the mouth of that doctor, you're never going to get diagnosed with Mycobacterium marinum, right? And yes, it was, I would say, total luck that that patient did come and see me. And I had remembered that one time in med school. And to be honest, to be fair, it's always a question on our boards.