Latest / Becker’s Healthcare Podcast / Physician Independence, Chronic Disease and the Human Operating System with Dr. Amy Gutman

Transcript

Physician Independence, Chronic Disease and the Human Operating System with Dr. Amy Gutman · Becker’s Healthcare Podcast

• 0:02
  - The strategic agenda facing hospital and health system
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  - leaders right now is not a short list.
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  - Growth in a consolidating market, sustainable margins in
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  - and a workforce story that is still being
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  - written.
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  - Eker's fourteenth annual CEO CFO roundtable brings together
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  - Not in the abstract, but against the real
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  - decisions they'll face heading into the next year.
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  - It's the kind of event you leave with
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  - a clear sense of where you stand and
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  - what comes next.
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  - So join us November second through the fifth
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  - at the Hyatt Regency in Chicago,
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  - and come ready to do the hard thinking.
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  - Register on our events page at beckershospitalreview.com
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  - by clicking on the events tab in the
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  - upper right.
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  - This is Scott Becker with the Beckers HealthCare
• 1:01
  - podcast.
• 1:02
  - We're thrilled today to be joined by a
• 1:03
  - brilliant physician leader. We're we're joined today by
• 1:06
  - doctor Amy Gutman, and Amy is gonna tell
• 1:08
  - us where she's most focused today, what trend
• 1:11
  - she's watching, and a lot more. She's a
• 1:13
  - fascinating career.
• 1:14
  - Doctor Gutman, can you take a moment and
• 1:16
  - introduce yourself,
• 1:18
  - and and tell listeners a little bit about
• 1:20
  - yourself and and your background?
• 1:22
  - Thank you so much. I I love that.
• 1:24
  - That's you're very kind. But I'm an emergency
• 1:26
  - medicine physician by training,
• 1:29
  - and I spend about half my time now
• 1:32
  - as a speaker,
• 1:34
  - spreading the word about
• 1:36
  - what I call the human operating system. So
• 1:38
  - it's the intersection of physiology and leadership and
• 1:40
  - human performance.
• 1:42
  - And I work through my company, Tough Love
• 1:44
  - MD, to help people and organizations
• 1:48
  - understand what I think is a really simple
• 1:49
  - idea. You you cannot ask a biologically depleted
• 1:53
  - human to
• 1:55
  - sustain performance at a high level. So
• 1:58
  - I think one of the things that comes
• 1:59
  - across in my
• 2:02
  - social media, and I know how we've connected
• 2:04
  - is my goal really isn't wellness for wellness
• 2:07
  - sake. It's better decisions, better leadership,
• 2:10
  - better performance, and,
• 2:12
  - hopefully, better outcomes for not just our patients,
• 2:14
  - but
• 2:15
  - our physicians and clinicians as well, the entire
• 2:18
  - system. So thank you again for having me
• 2:20
  - on. I appreciate it. No. It it a
• 2:22
  - total pleasure, and I'm always inspired by your
• 2:25
  - thinking and what you do and how you
• 2:27
  - approach things. Talk a little bit about when
• 2:29
  - you think about tough love and the concept,
• 2:32
  - what what does that make you think of,
• 2:33
  - and what does that look like in practice?
• 2:36
  - Absolutely.
• 2:38
  - So, actually, if I might can I fangirl
• 2:40
  - for just a second over your, latest book?
• 2:42
  - So the Building Great Businesses. I was so
• 2:44
  - excited to see it because
• 2:47
  - your
• 2:48
  - first it no. It wasn't your first book.
• 2:49
  - I think it was your second or third
• 2:50
  - book about
• 2:52
  - blocking and tackling. It's one of the first
• 2:53
  - books I read about
• 2:56
  - health care
• 2:57
  - leadership, and it was around the time that
• 3:00
  - I had to kinda give myself
• 3:02
  - some tough love. Tough love is
• 3:04
  - essentially the unpleasant
• 3:07
  - truce versus kind lies.
• 3:09
  - How do we kick ourselves in our businesses
• 3:11
  - when we're in a bit of a social
• 3:14
  - political environment where
• 3:16
  - we spend a lot of time being kind,
• 3:18
  - but it's ended up with this
• 3:20
  - horrible
• 3:21
  - pandemic of chronic disease and illness, which
• 3:25
  - pervades not just personal lives, but our organizations
• 3:28
  - as well.
• 3:30
  - And
• 3:31
  - one of the things I took away from
• 3:32
  - your initial book is, like, the fundamentals
• 3:34
  - of practical,
• 3:36
  - not just business, but how to live your
• 3:38
  - life. And it continues in your current book.
• 3:41
  - And I and I apologize. I'm gonna mangle
• 3:44
  - it again. But as you you talk about
• 3:45
  - great markets that are not just winnable, but
• 3:47
  - worth winning. To me Yes.
• 3:50
  - Yeah. Exactly. And so
• 3:52
  - I approach health care
• 3:54
  - in kind of a really diverse way. I
• 3:57
  - am really vested in
• 3:59
  - physician independence
• 4:02
  - because
• 4:03
  - which is a very tough thing. And sometimes
• 4:05
  - you have to give that tough love. Like,
• 4:07
  - I I'm for me,
• 4:09
  - I was so comfortable
• 4:10
  - being an emergency physician working for a large
• 4:12
  - corporation, but I had no ownership.
• 4:15
  - And when I got sick, I had no
• 4:17
  - ownership over
• 4:18
  - that.
• 4:20
  - And then you look and you go, well,
• 4:21
  - I have no ownership over the health care
• 4:23
  - system. I have no ownership over these things
• 4:25
  - that should bring me
• 4:27
  - happiness.
• 4:28
  - So to me, the fight of tough love
• 4:30
  - is not just,
• 4:32
  - fight the fights that need
• 4:34
  - fighting. You fight the fights that need to
• 4:36
  - be fought. I think that's actually a line
• 4:38
  - from the American president. Oh, did you plagiarize
• 4:41
  - from the American president? Oh, no.
• 4:44
  - No. You're fine. I just realized.
• 4:46
  - No. No. You're you're you're fine, but that's
• 4:48
  - exactly right. You're you're trying to always pick
• 4:50
  - the right battles. When we talk about markets,
• 4:52
  - is it can you win in it, and
• 4:54
  - is it worth winning in? Right. And this
• 4:56
  - issue of this issue of physician independence
• 4:59
  - is a it seems like
• 5:02
  - that if that's an important goal, and and
• 5:05
  - I'm generally a believer that there's huge amounts
• 5:07
  - of positives and a lot of us being
• 5:09
  - stakeholders in the economy,
• 5:11
  - which means lots of independent businesses, lots of
• 5:13
  - independent physicians,
• 5:15
  - that there's just all kinds of benefits to
• 5:16
  - that as part of the fabric of American
• 5:19
  - life.
• 5:20
  - Is that still a winnable battle or is
• 5:22
  - that something that's moved towards just mega business,
• 5:25
  - mega corporations
• 5:27
  - so the era of independent physicians is
• 5:30
  - is coming to an end, or is there
• 5:32
  - still hope for it?
• 5:34
  - How do you think about that, doctor Gutman?
• 5:35
  - Do you do you see that out there?
• 5:37
  - Is there still hope for independent physicians, or
• 5:39
  - what does that look like? Oh, absolutely. And
• 5:41
  - I actually really think
• 5:43
  - that
• 5:44
  - the problems that we're having in the health
• 5:46
  - care system overall are driving physicians towards that.
• 5:50
  - I think a really good example, a substitute
• 5:53
  - who is very much in the media recently
• 5:55
  - is,
• 5:56
  - doctors Kaufman for cough care.
• 5:59
  - And so he has taken a lifetime in
• 6:02
  - emergency medicine,
• 6:03
  - and also things like American Ninja, which, again,
• 6:06
  - interesting. It makes him a whole person. Right?
• 6:09
  - But he has designed
• 6:11
  - a
• 6:12
  - sort of unemergency
• 6:14
  - care office, and it's tackling
• 6:17
  - what are considered urgent care or more emergent
• 6:19
  - problems independently
• 6:21
  - of a hospital system, independently of an emergency
• 6:24
  - department. Not a not a freestanding emergency department,
• 6:26
  - which
• 6:27
  - can be good or problematic, but independently.
• 6:30
  - And
• 6:31
  - the more people I speak with are, hey.
• 6:33
  - These are independent orthopedic
• 6:35
  - physicians. These are independent pediatricians.
• 6:38
  - People who work outside of health care because
• 6:40
  - they're driven
• 6:42
  - to that. And
• 6:44
  - I think
• 6:45
  - one of the things that has come up
• 6:46
  - most recently is the
• 6:49
  - new proposed
• 6:51
  - changes coming up in, I believe it's July,
• 6:54
  - the,
• 6:55
  - 02/2027,
• 6:56
  - the Medicare physician fee schedule proposed changes, which
• 7:00
  - I think will
• 7:02
  - devastate
• 7:03
  - physicians who are trying to be independent,
• 7:07
  - because they get paid for that first visit
• 7:09
  - at a 100% and the second visit at
• 7:11
  - 25 to 50%
• 7:13
  - to avoid some of those,
• 7:15
  - stark law
• 7:16
  - challenges that I'm referring to myself.
• 7:19
  - I think health care realizes
• 7:22
  - that a lot of people want to be
• 7:24
  - independent. A lot of clinicians do not want
• 7:26
  - to work for these mega corporations,
• 7:28
  - which, again, some of them are very good
• 7:30
  - and protective, and some of them aren't, as
• 7:32
  - you know.
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  - But
• 7:35
  - I think
• 7:37
  - we're gonna head towards an era where people
• 7:40
  - have that choice. They can have a physician
• 7:43
  - that manages their internal medicine
• 7:46
  - and a physician that happens to handle their
• 7:48
  - cardiology
• 7:49
  - or ortho.
• 7:50
  - The the thing
• 7:51
  - and I'm sure you're seeing too, is the
• 7:54
  - rise of precision medicine.
• 7:56
  - Some people
• 7:57
  - call functional medicine. That's a little problematic to
• 8:00
  - me because
• 8:01
  - sometimes we don't see necessarily physicians involved with
• 8:03
  - that.
• 8:05
  - But precision medicine where a patient
• 8:08
  - can work within a hospital system for things
• 8:11
  - that they need that can only be done
• 8:13
  - in a hospital,
• 8:15
  - but manage their daily care with a one
• 8:17
  - to one physician that they establish a relationship
• 8:21
  - within.
• 8:22
  - And you know as well as I do
• 8:24
  - that the more vested a patient's clinician is
• 8:28
  - in their care, the better the patient's outcomes
• 8:30
  - are gonna be.
• 8:32
  - Yeah. And the healthier the physician the patient
• 8:34
  - feels because they've got they're more disconnected, which
• 8:36
  - connectivity as a big part of everything. But
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  - how do we do that in a spot
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  - where we've only got 900,000
• 8:42
  - or so practicing physicians,
• 8:44
  - a a population of 350,000,000
• 8:46
  - people?
• 8:47
  - How do we are there substance for that?
• 8:49
  - Can the nurse practitioner, the PA, do some
• 8:52
  - of that? How do we because we we
• 8:54
  - just don't have the numbers,
• 8:56
  - I don't believe,
• 8:57
  - to provide care the way that we'd like
• 8:59
  - to provide it or certainly the way that
• 9:01
  - I grew up with my primary care physician.
• 9:03
  - Yeah. How how do we manage that when
• 9:06
  - it seems like the numbers are just so
• 9:08
  - daunting at 900,000
• 9:09
  - plus,
• 9:10
  - you know,
• 9:11
  - physicians compared
• 9:13
  - to 350,000,000
• 9:15
  - people and, you know, you've got 33,000
• 9:17
  - or so physicians starting medical or DO school
• 9:20
  - a year, twenty, twenty five thousand retiring a
• 9:22
  - year. I mean, how do you make some
• 9:25
  - of those numbers actually work? Is is, I
• 9:27
  - guess, my
• 9:28
  - question because, you know, I love my primary
• 9:31
  - care physician. I've known him my whole life.
• 9:33
  - He's fantastic.
• 9:34
  - He knows me. I feel connection.
• 9:36
  - It makes it much easier for me to
• 9:37
  - talk about everything and deal with everything, you
• 9:39
  - know. And I'm 60 years old, so I've
• 9:41
  - got plenty of issues.
• 9:43
  - But but it just seems like that that
• 9:45
  - is coming to an end. Then he retires
• 9:48
  - if I want that same relationship. I want
• 9:50
  - to face somebody that exorbitates them out for
• 9:52
  - for, you know, for,
• 9:54
  - counseling or cure or something because there's just
• 9:55
  - not enough physicians.
• 9:57
  - So, yeah, it's a dual phase problem in
• 9:59
  - that,
• 10:01
  - so I think
• 10:02
  - the entire purpose of
• 10:05
  - the wave of nurse practitioner and physician assistant
• 10:07
  - programs and I don't know if you know
• 10:09
  - this, if we've talked about it. I was
• 10:10
  - a PA for many years before I went
• 10:12
  - back to med school, and I became very
• 10:14
  - frustrated by my limitations
• 10:16
  - in that
• 10:17
  - I wanted to care for patients at a
• 10:19
  - little bit higher level.
• 10:20
  - The the problem with nurse practitioners
• 10:22
  - and mid levels who are a very well
• 10:25
  - trained group is they just don't replace a
• 10:28
  - physician.
• 10:29
  - They can do a lot of things a
• 10:31
  - physician do, but the training
• 10:33
  - is not the same. And it's not the
• 10:35
  - same for years or for exposures.
• 10:38
  - And, unfortunately,
• 10:39
  - a lot of the people who went to
• 10:41
  - school as a nurse practitioner to, quote, you
• 10:43
  - know, take care of the patient are doing
• 10:45
  - a lot of things like IV therapy and
• 10:46
  - wellness clinics and things, not taking care of
• 10:49
  - the patient.
• 10:51
  - The problem ultimately is not training
• 10:55
  - a ton of physicians and getting them out
• 10:57
  - quickly into society, which some medical schools are
• 10:59
  - actually proposing to cut that education, which I
• 11:01
  - think is a grave error.
• 11:04
  - The problem is that seventy nine percent of
• 11:07
  - us across the world have at least one
• 11:09
  - chronic disease.
• 11:11
  - And as long as we are dealing with
• 11:14
  - a very sick population,
• 11:16
  - it will be very difficult to maintain those
• 11:18
  - relationships with a physician. You are very lucky.
• 11:21
  - You've had a physician that you've had for
• 11:22
  - years you have great relationship with, but you're
• 11:25
  - already
• 11:25
  - somewhat panicking because, oh gosh. This guy's gonna
• 11:28
  - retire. What do I do?
• 11:30
  - We don't want patients doing that because, ultimately,
• 11:32
  - they end up in my emergency department.
• 11:35
  - The more patients who don't have a good
• 11:37
  - clinician relationship, the more end up in my
• 11:39
  - emergency department three in the morning because they've
• 11:41
  - run out of prescriptions. So so classically, Scott,
• 11:44
  - I'll see somebody come in at midnight.
• 11:47
  - Like, I'm out of my blood pressure medication
• 11:49
  - prescription.
• 11:50
  - And they they've been through four or five
• 11:52
  - different physicians in that office or maybe they're
• 11:55
  - in a residency clinic who will not see
• 11:57
  - them because they've had five refills
• 12:00
  - and will not fill their prescription until they
• 12:02
  - get into the office. Okay. Well, the next
• 12:03
  - appointment is three to four months away. There's
• 12:05
  - not enough physicians there. And so they end
• 12:08
  - up in the ED. Hopefully, it's just for
• 12:10
  - a refill, but often because they're having a
• 12:12
  - crisis related to the fact they don't have
• 12:14
  - a physician.
• 12:16
  - So we go back to the idea of
• 12:18
  - concierge.
• 12:20
  - Concierge is actually not as expensive depending on
• 12:23
  - what you want. If you were somebody who's
• 12:25
  - like, listen.
• 12:26
  - I need
• 12:27
  - a person
• 12:29
  - or a group, maybe a small group, to
• 12:31
  - just take care of my basic needs.
• 12:33
  - It's actually when you look at that as
• 12:35
  - compared to
• 12:37
  - the cost of not seeing a physician,
• 12:41
  - and that's
• 12:42
  - a now cost versus a later cost,
• 12:45
  - of course.
• 12:46
  - It's actually
• 12:47
  - a lot cheaper
• 12:48
  - to actually have a physician involved in your
• 12:50
  - life early on. But the other thing that
• 12:52
  - we're seeing is the rise of AI, your
• 12:55
  - your conference coming up in September.
• 12:58
  - So for example, I went to a lab
• 13:01
  - yesterday.
• 13:03
  - I ordered my own labs. I had a
• 13:05
  - physician who is over the lab approve them,
• 13:08
  - but they had, hey. It's a cardiovascular health
• 13:11
  - lab. It's an immune lab. It's all these
• 13:13
  - labs. You can download them. You can bring
• 13:16
  - them to your physician so you're avoiding okay.
• 13:18
  - That first visit that took me three months
• 13:20
  - to get. Okay. We're gonna order labs, and
• 13:22
  - I'll see you again in three months. Well,
• 13:24
  - now you've gone half a year
• 13:26
  - without a physician because you don't have access.
• 13:29
  - Now you can do a lot of the
• 13:30
  - things by yourself for a fairly low cost,
• 13:35
  - not to replace a physician, but replace in
• 13:37
  - some ways that
• 13:39
  - easy access.
• 13:41
  - I don't think, Scott, we're gonna have a
• 13:43
  - good answer until
• 13:46
  - we fix
• 13:47
  - the chronically ill bits of society, which is
• 13:49
  - a
• 13:50
  - if you have the answer to that one,
• 13:53
  - that's your next best seller. Because I think
• 13:55
  - that's I don't have I don't have that
• 13:57
  - answer.
• 13:58
  - No. I think those are very challenging issues
• 14:00
  - just in terms of, like, how do you
• 14:01
  - mix the workforce to make this work? How
• 14:04
  - do you get people that personal attention? How
• 14:06
  - do you get people taken care of? How
• 14:07
  - do you take care of the, you know,
• 14:09
  - whatever tens of millions of people that are
• 14:12
  - sort of a little bit lost in society
• 14:14
  - on top of, you know, everybody else? You
• 14:17
  - know, how do you sort of deal with
• 14:18
  - these things? And, of course, you got tens
• 14:19
  - of millions of people that have chronic conditions,
• 14:22
  - and it's all over the board in terms
• 14:23
  - of the continuum of how much continuous regular
• 14:25
  - care they're getting for their chronic conditions too.
• 14:27
  - Right. So, no, I I I do I
• 14:29
  - do think it's a it's a real challenge.
• 14:30
  - And it's a a mix of workforce strengthening,
• 14:35
  - you know, increasing the number of physicians,
• 14:38
  - and making the physician life a a a
• 14:42
  - little bit less burnout
• 14:44
  - in intense, a little bit more manageable.
• 14:47
  - And to do that, you know, we we
• 14:48
  - always talk about in staffing teams, staffing companies,
• 14:51
  - staffing groups
• 14:52
  - that if you don't have sufficient capacity,
• 14:56
  - it's very hard to fight burnouts because everybody's
• 14:58
  - always just trying to hit to catch up.
• 15:01
  - And, you know, you could do all the
• 15:02
  - nice things you want. Like, people are talking
• 15:03
  - about Silicon Valley. You got the ping pong
• 15:06
  - tables and massages, the this, that, the other.
• 15:08
  - But it's all it's it's all relevant
• 15:10
  - whatever you're doing culturally if you don't have
• 15:12
  - enough people to take care of people,
• 15:15
  - because people are just, exhausted. You know?
• 15:18
  - And hospital closings add to that. So I
• 15:21
  - have,
• 15:23
  - I met a wonderful woman who is
• 15:26
  - just got a large government grant to help
• 15:27
  - reform reef, rural health care
• 15:30
  - in Florida. I my locums jobs are always
• 15:33
  - in well, I won't say always, but the
• 15:35
  - majority are in very, very rural places. And
• 15:37
  - when one hospital shuts down
• 15:40
  - so there may not be a family practice
• 15:42
  - or internal medicine doctor for
• 15:44
  - two hours, a drive in any distance. So
• 15:47
  - those patients, of course, then add to the
• 15:49
  - emergency department. Why is my wait so long
• 15:51
  - in the emergency department? Well, because now I
• 15:52
  - have all this primary care. So you're right.
• 15:55
  - It just
• 15:56
  - it
• 15:57
  - kind of goes from one small problem to
• 16:00
  - escalating, escalating, escalating. We have a complete breakdown.
• 16:03
  - Very difficult. No. And it really is. And
• 16:05
  - it really is a domino scenario. Like, you
• 16:06
  - go you look at these sort of emergency
• 16:08
  - departments, their place. Ten years ago, they're advertising,
• 16:10
  - we'll get you in and out in thirty
• 16:11
  - minutes. Now you're at three hour waits in
• 16:13
  - many places. It's behavioral health. It's primary care.
• 16:16
  - It's a lot of things. And there is
• 16:18
  - this concept by hospital administrators that I hate
• 16:21
  - where periodically, they'll blame the patients for going
• 16:24
  - to the ER.
• 16:26
  - And all of us as patients, consumers, are
• 16:28
  - creatures of habit or creatures of what's the
• 16:30
  - lowest common denominator.
• 16:32
  - So we end up there because we haven't
• 16:34
  - found other good access points. Not that we
• 16:36
  - want to be there. It's that that's the
• 16:38
  - easiest access point at that point in time,
• 16:40
  - so we end up there. And there's a
• 16:41
  - lot of that, and we see it in
• 16:42
  - every family. I mean, it's it's the reality
• 16:44
  - of,
• 16:45
  - us as consumers.
• 16:47
  - It's where
• 16:48
  - the American consumer is very smart. They end
• 16:50
  - up going to where the easiest place to
• 16:52
  - go to is, and that's why ERs are
• 16:53
  - so crowded again, and hospitals don't have places
• 16:56
  - to discharge patients to. Patients don't have easy
• 16:59
  - access points in the front end, so they
• 17:00
  - end up back in these spots. Exactly.
• 17:03
  - No. Absolutely. And it it's a difficult thing
• 17:06
  - because and I will admit. I mean, I
• 17:08
  - try to be a good human most of
• 17:09
  - the time, but 03:00 in the morning when
• 17:12
  - somebody comes in for their, quote, emergency pelvic
• 17:14
  - exam. Well, there's no such thing as an
• 17:16
  - emergency pelvic exam, certainly, and I get a
• 17:19
  - little cranky at that. And it's because well,
• 17:21
  - I've had this problem for six months. I
• 17:23
  - can't get into my OB. I just got
• 17:25
  - off shift at, you know, wherever I work
• 17:27
  - at 02:30.
• 17:28
  - This is my daytime, and I don't have
• 17:30
  - any other options.
• 17:32
  - And so I try to be a good
• 17:34
  - human and not be cranky at that because
• 17:36
  - it's a complete
• 17:38
  - nonemergency.
• 17:39
  - But for that patient,
• 17:40
  - it is.
• 17:42
  - The the other issue that we have is
• 17:45
  - so let's say I can even get them
• 17:48
  - to an OB guy. Let's say, look. One
• 17:50
  - of the rural hospitals I work at, and
• 17:52
  - a lot of rural hospitals have this model
• 17:53
  - of they have a visiting doctor come. So,
• 17:56
  - like, Monday will be cardiology, Tuesday will be
• 17:58
  - ortho, etcetera, which I think is lovely
• 18:01
  - except for the
• 18:03
  - okay. I'm gonna get into the OBGYN on
• 18:05
  - Wednesday.
• 18:06
  - They can't do everything they need to do,
• 18:07
  - so we're gonna set up another time and
• 18:09
  - date for what you need, and we'll see
• 18:11
  - you again in six months because that's the
• 18:13
  - next time around.
• 18:14
  - And they don't have $40
• 18:17
  - in gas to drive to the next place.
• 18:19
  - They don't have the money to pick up
• 18:21
  - their medication at the pharmacy.
• 18:23
  - And so it's
• 18:25
  - rather than helping, you're putting a very ineffective
• 18:27
  - Band Aid on
• 18:29
  - a very bad problem. So
• 18:32
  - it is a very contentious discussion. I know
• 18:35
  - you've commented on it. The idea and please
• 18:38
  - excuse. I don't remember the state. There is
• 18:41
  - a state in the Midwest
• 18:43
  - that is
• 18:45
  - allowing
• 18:46
  - physicians who have trained outside The US, experienced
• 18:49
  - physicians to practice in The US without a
• 18:52
  - fellowship residency in The US.
• 18:56
  - And that has been met with
• 18:58
  - huge pushback certainly from the large physician representation
• 19:03
  - agencies, like, you know, with the AMA and
• 19:05
  - such. It does not speak for the majority
• 19:07
  - of physicians, of course.
• 19:09
  - But it is a way of like, hey.
• 19:11
  - If you wanna practice in The US, you
• 19:13
  - can,
• 19:14
  - but you have to practice in family practice
• 19:16
  - and primary care. If you wanna come from
• 19:18
  - another country with that,
• 19:20
  - I have both positive and negative thoughts about
• 19:23
  - it because I have worked overseas. Yeah. I've
• 19:25
  - worked overseas. I've worked with some of the
• 19:27
  - most brilliant physicians
• 19:29
  - who truly are brilliant physicians but can never
• 19:31
  - practice here. But I've also worked with,
• 19:35
  - physicians who are very experienced but very poorly
• 19:38
  - educated.
• 19:39
  - A 100%. It it it it's almost what's
• 19:41
  - happened with, it with
• 19:44
  - yes. No. I think it's a it's a
• 19:45
  - it's a real challenge because
• 19:48
  - necessity is always is some other invention. So
• 19:50
  - people end up sort of bending the rules
• 19:52
  - on these things because we just need more
• 19:53
  - doctors, and then you end up with some
• 19:55
  - doctors that are great, some that are not.
• 19:57
  - And it's and it's a real challenge and
• 19:59
  - a real evolution.
• 20:00
  - And and there are all kinds
• 20:02
  - of issues and challenges. We've moved with expedited
• 20:05
  - nurse education in our country along tremendously the
• 20:08
  - last few years. And that has really helped
• 20:10
  - fill a gap, and you still have people
• 20:12
  - that very much complain, oh, these nurses aren't
• 20:14
  - as well trained. Well, but it's far better
• 20:15
  - than the alternative,
• 20:16
  - which we were so short on nurses. So
• 20:18
  - it's it's it's a complicated
• 20:19
  - middle ground on a lot of this stuff.
• 20:22
  - And, you know, I I also see a
• 20:23
  - big hole in our system in terms of
• 20:25
  - training specialists and subspecialists.
• 20:27
  - You know, you see, like, the amount of
• 20:29
  - cancer diagnosis versus the amount of oncologists. It's
• 20:32
  - just the numbers are are are are daunting.
• 20:35
  - In any event, doctor Gautman, we've gotta wrap
• 20:38
  - up in a moment.
• 20:39
  - Anything else you'd like to share with the
• 20:41
  - listeners about tough love and what you do?
• 20:43
  - Because I find you just to be fascinating
• 20:45
  - and a fantastic leader. Anything else you'd like
• 20:47
  - to share today?
• 20:48
  - Well, so two things. One, again, I I
• 20:52
  - have to tell you that
• 20:53
  - in
• 20:54
  - one of your,
• 20:56
  - books, you in fact, I think it was
• 20:57
  - this most recent one, you talked about
• 21:00
  - being respected, having respective,
• 21:02
  - clients. The clients that are respected gives your
• 21:05
  - business credibility. And I think,
• 21:07
  - aligning with you, you've been so kind to
• 21:09
  - me, and that's been very helpful. But it
• 21:11
  - allows me to do
• 21:13
  - my job because I
• 21:15
  - am absolutely renewed every day when people who
• 21:19
  - are outside of traditional medicine.
• 21:21
  - And I think, like, not physicians, not clinicians,
• 21:23
  - are renewing the focus on chronic disease and
• 21:25
  - metabolic health, which you focus on. You focus
• 21:28
  - on the business of medicine, which is really
• 21:30
  - important to me because it lets me do
• 21:32
  - my job because
• 21:33
  - chronic disease is explicitly
• 21:37
  - a federal health priority now.
• 21:40
  - And I think the answer to a lot
• 21:42
  - of these underlying questions is being really tough,
• 21:45
  - not just on ourselves as physicians and saying,
• 21:47
  - what do we need to do to make
• 21:49
  - our patient population better?
• 21:51
  - But also at patients
• 21:53
  - becoming better educated on addressing their own biology.
• 21:56
  - It precedes the disease
• 21:58
  - rather than just becoming
• 22:01
  - like, finding a new way of managing disease
• 22:03
  - after it arrives. So,
• 22:05
  - yes, we need more physicians, but they really
• 22:07
  - do have to be trained. Yes. We need
• 22:09
  - to get rid
• 22:11
  - of the chronic disease that disables seventy nine
• 22:14
  - percent of the world, or we're never gonna
• 22:16
  - be able to solve problem a. And maybe
• 22:19
  - number three,
• 22:21
  - like, really reaching into yourself and going, am
• 22:23
  - I happy at work? And if I'm not,
• 22:26
  - what do I need to do to fix
• 22:27
  - myself? And for a lot of people, that
• 22:30
  - is the rise of independent physicians. So that's
• 22:33
  - my tough love.
• 22:35
  - And,
• 22:35
  - again, thank you very much for allowing me
• 22:38
  - the conversation today.
• 22:41
  - No. We we love that, and we love
• 22:42
  - everything about that. We love that third point
• 22:45
  - about am I happy at work, and what
• 22:46
  - can I do to change it? What can
• 22:48
  - I do to think about? And where that
• 22:49
  - leads, I don't know.
• 22:51
  - But I think this concept of are you
• 22:52
  - satisfied? Are you thriving? Are you helping? Are
• 22:55
  - you impact are you having impact? And are
• 22:57
  - you enjoying it? You know? Are Right. Multiple
• 23:00
  - different pieces. And and and, you know, I
• 23:02
  - I remember periods of time when I was
• 23:03
  - first, you know,
• 23:05
  - just trying to make a living. And I
• 23:06
  - don't know that I always enjoyed it, but
• 23:08
  - it was challenging and and and certainly, interesting.
• 23:11
  - You know? Then periods of time, other periods
• 23:13
  - of time, I enjoy it more than when
• 23:14
  - I was just trying to make a living.
• 23:16
  - But both are are challenging different parts of
• 23:19
  - of of of contributing to society. And and
• 23:21
  - I think it's a fascinating challenging question for
• 23:23
  - all of us.
• 23:24
  - Yeah. What what is the impact you wanna
• 23:26
  - make in the world? And that's great. But
• 23:28
  - if you come home every day and you
• 23:31
  - haven't had your kid and you're not happy
• 23:33
  - and
• 23:34
  - you are overweight and ill,
• 23:37
  - is that impact
• 23:38
  - worth it? And so we have to keep
• 23:41
  - ourselves in that equation too, and we often
• 23:43
  - forget that part of it.
• 23:45
  - So and I don't think
• 23:47
  - that new generation of physicians isn't forgetting about
• 23:50
  - it. They seem to be a little bit
• 23:52
  - more focused on
• 23:54
  - their, quote, me time. So good for them
• 23:56
  - in a way,
• 23:57
  - but but it also is if,
• 24:00
  - it it also leads to a lot of
• 24:01
  - physicians who are like, I'm gonna rock climb
• 24:03
  - for half the week and only work twenty
• 24:05
  - hours in the office zone. Well well Yep.
• 24:09
  - Well and and it's it's,
• 24:11
  - it it it's really challenging. And if if
• 24:13
  - they pay it for their own education, they
• 24:15
  - do it their own way, you know, they've
• 24:17
  - got a lot of flexibility to choose what
• 24:19
  - they want to do. You know, if if
• 24:21
  - the if, you know, if the system paid
• 24:23
  - for your education,
• 24:24
  - maybe you owe the system a little bit
• 24:26
  - more. I don't know. But I think the
• 24:27
  - answer is not to say to people you
• 24:28
  - can't go part time. You can't do things
• 24:30
  - you wanna do. The the real answer is
• 24:32
  - to create more physician spots and more residency
• 24:35
  - spots. We have more physicians so that people
• 24:37
  - can be physicians and live the lives they
• 24:39
  - wanna live, which are maybe different than how
• 24:41
  - you or I grew up practicing whatever profession
• 24:43
  - we're in. You know? And and that's okay.
• 24:46
  - Both for patients
• 24:47
  - and for physicians, I think drives a lot
• 24:49
  - of this. So it will be interesting to
• 24:51
  - see how it plays out. And,
• 24:54
  - I I speak on behalf of a lot
• 24:57
  - of physicians who have done it a very,
• 24:59
  - different way.
• 25:01
  - It's a great way
• 25:04
  - to sit back and go, okay. I've given
• 25:07
  - a lot to people. I wanna continue to
• 25:08
  - give a lot to people, but I need
• 25:10
  - to kinda make sure that I'm at the
• 25:12
  - center of it. Because if what is it?
• 25:14
  - Take the first pulse you're taking in emergency
• 25:16
  - as your own. Right? A 100%.
• 25:18
  - No. That's exactly right. If you can't take
• 25:19
  - care of yourself, you can't take care of
• 25:20
  - others. It's the truest statement ever. Doctor Gutman,
• 25:22
  - I wanna thank you so much for joining
• 25:24
  - us. As always, it's always great to visit
• 25:25
  - with you. Thank you so much for joining
• 25:27
  - us today. Thank you so much, Scott. I
• 25:29
  - appreciate you.