Latest / Faisel and Friends: A Primary Care Podcast / Ep. 2: Licensed to Treat, Expected to Lead w/ Dr. Jack Cochran
Transcript
- Dr. Faisel Syed [00:00:14] I'd like for everyone to think for a moment about the value of human life. And does one person's life have any more value than another person's? The current fee-for-service health care system rations out care based on the patient's ability to pay. I believe this is unethical. It is criminal. 95% of the country is still functioning on this fee-for-service model. I believe everyone should be treated the same. Everyone should have access to primary care regardless of their ability to pay. Hi, I'm Dr. Faisal said. Welcome to another episode of Faisal and Friends. We're here because we believe everyone needs access to quality primary care, and Chen Med needs physicians to take care of them. Today's topic is licensed to treat expected to lead. I am very thrilled about our friend joining us tonight. I was introduced to Dr. Jack Cochran by Dr. Paul Grundy. And since our quick introduction, we've become quick, fast friends. An introduction about Dr. Cochran. Dr. Cochran is an innovative leader for health care transformation, and his 2018 book, Healer, Leader, Partner. He provides practical, proven knowledge and skills for physicians to become effective, compassionate leaders for improving and transforming health care to deliver on what patients want, need, and deserve. Under his leadership as the executive director CEO of the Permanente Federation, Kaiser Permanente was recognized as a national leader in clinical quality by multiple institutions, including the Medicare Star Program and the National Committee for Quality Assurance and Secure it. The Federation represents the national interest of the regional Permanente medical groups, which employ 20,000 plus physicians who care for more than not 10,000,012 million Kaiser Permanente members. Welcome, Dr. Jack Cochran. Dr. Jack Cochran [00:02:28] Thank you. Good to be here. Dr. Faisel Syed [00:02:30] You know, Dr. Cochran, I would like to take you back to the 1990s. Robert Longyear [00:02:36] You were involved in that in the kind of the throes of a beginning of managed care. You were leading a large organization. Now, what would have what would you have done differently if you could do things over again with today's resources and health care? Dr. Jack Cochran [00:02:52] Well, gosh, that's a pretty long list. I think, probably, to simplify it, I would have had more conviction over some of the things I saw and thought you change and wanted to change. But I had a level of inexperience that didn't necessarily translate into the boldness and the conviction that I needed. You know, just briefly, I was a pediatric plastic surgeon, and to do that, I had four years of medical school and six years of surgery residency before I went to Kaiser. I had eight years of practice, and I've been certified, qualified, examined. You know, I had all of that sort of context for core competence. Then I went to KP. I went on the board. Two years later, I was elected the president of the region. And that's the leadership of the clinical and the business side of health care. Sure. At that time, you know, 700, 800 doctors in a region the size of Colorado or a thousand patients. But for that job, my training was on the job just in time, trial and error. And so that's what I mean, my conviction, I, I learned on the job about leadership and business, and probably in some weird way, my inexperience had some advantage because I was aware that I was inexperienced and I spent a lot of time listening and listening to physicians and listening to Primary care from my specialty care practice world. I would have never understood. So I think I learned a lot of things that I tried to put into practice, and I eventually did. But I think if I had a little more conviction earlier on, I might have moved quickly. Robert Longyear [00:04:42] Right. Right. So you went from being a plastic surgeon, highly trained at your craft, very precise, to having to run an organization and very different set of skills. You know, in plastic surgery, you are sort of it's you and the patient in a lot of circumstances. You have a lot of control over the situation. But now you're managing people. You're managing organizations, and you're getting a whole bunch of them. What did you have to sort of we've touched on it a little bit, but what did you have to do to sort of change your mindset and sort of what were some situations you got into that you never, never thought that you would have to be prepared to deal with? Dr. Jack Cochran [00:05:20] You know, another long list? Well, first of all, the job of being the president of the regional physician group is a job that is a selected job by the physicians and their board of directors. So I went through a review and selection process by my peers. And I will tell you what they said about me that they found. Reasonably positive that I was very balanced, that I was sort of a very focused doctor. Doctor, in other words, they call me at three in the morning with a dog, but I didn't give them a reason that I was crabby and didn't go. And so they respected me as a clinician. They thought I had a balanced view. And they and they also said that you know, he's willing to speak up. And so there was a few sort of odd traits that they found to be desirable. And then, I got involved in a selection process where they asked us to think out loud, and they thought that perhaps I had some of the traits that we wanted. But as I just said earlier, I was very aware of what I didn't know. And while I was scared and, you know, that was that that didn't make me feel old. I hit the road, and I met with I did a listening tour, and I met with every position in the group in groups of five or less for six weeks every hour. I met with every group, but I took notes just to say, What is going on? What is that? What is the issue in primary care, what is the issue in referrals, etc? So, you know, it was a little mini tutorial on reality, and I'm really glad I did it. I recommended that behavior anyway, take a new job. You know, you've got all your assumptions and all your knowledge. Go test them. Go tested with the people that really help you. Dr. Faisel Syed [00:07:08] I read part of your book, and you obviously and have a fair amount of confidence to make this change in the leadership. And in your book, you describe a scenario where the difference between arrogance and confidence. So doctors are often considered to be arrogant. I'll talk about that a little bit about the importance of confidence without arrogance. Dr. Jack Cochran [00:07:32] Yeah, actually, I wrote a little piece about that after doing a 16-hour operation with eight surgeons one day, and I was watching these two lead surgeons. I was one of the leads, and one was just just a complete shock walking all around talking about this stuff and sort of bragging about this and that, and the other one just quietly getting the job done. And I was just watching these two, and I thought it kind of framed that for me. I think that confidence is a quiet trait. Confidence is a sense that I'm grounded in reality. I see what I see, and I'm pretty sure it's true. And I think that on balance, I need there have some thoughts, some skills, or some ideas that can contribute to the solution. Or I've got some friends and colleagues and teammates that can help me with that. And so I think confidence is a fairly quiet trait, and it doesn't need to be acknowledged or being the center of attention, whereas arrogance really demands attention and demands that I notice noticed. And here and there, you get to think of me as being special. So I think I think that's the difference. And I didn't know. I also learned something else along myself, which is that, at the risk of Brian, I didn't know. I didn't know I was a good listener. And that was that was on the job panic. I had to figure out what's going on, and I just didn't have a way. I wasn't clairvoyant. So I became a good listener and that was a trait that I didn't necessarily have, but I developed a very apple. And the other was I was courageous. And I didn't know if I was courageous. I never thought about myself in that trait. And the reason I know that is that you do have to make some hard decisions, and you do have decisions that affect people and hard decisions that are on one pillar. And I had that sort of quiet sense of I've got the job, I've got the responsibility. I better at least go into it with, you know, full, full bore. I'm going to do the best I can, even if I make a few mistakes. And so I was actually fairly courageous. I didn't know that about myself, but it taught me a lot and I learned a lot. We can talk about it some of the time, but another question is about the power of personal forgiveness. Robert Longyear [00:09:58] So Dr. Cochran, Fassel sent me sending me questions since you can't be here at the moment. So let me ask you this. So you've worked extensively with national health policy developments, integrated care, innovation and physician leadership, and a very large, influential organization. And, you know, at the time you were there, Kaiser attained a national status for clinical quality recognized by a number of organizations, but it also completed the largest civilian deployment of a clinical information system. And as a health tech person, the EMR and clinical information system world is fraught with issues and challenges. And what was it like making the transition from paper charts and how do you feel about medical records and the status of the electronic health record today? Dr. Jack Cochran [00:10:47] Yeah, it's a great, great question. Probably worth a to our answer, right? First of all, Kaiser did do a lot of good things and got better. Didn't start out early, but got better, developed sort of a learning organization. And I say that because. Ten meters is exactly the same kind of organization. What you have is a culture that recognizes you will have a clear destination, you will have a mission. It was very eloquently spoken in the intro, and I thought that was very clear. There is a right and people have the right to get good primary care and good access. So we start with that. We believed that and then we developed a culture that embraced measurement. And when you come from a small single doc to private practice, most of the measurement of your success is how many chairs are occupied in your waiting rooms, right? If you've got a cold waiting room, you're probably doing a good job. There's no sense of what my real revision rate, infection rate, etc. was. So I think that we had a clear destination that we believed in. We developed a culture that embraced measurement and measurement. Scary when you start out because you're going to find out things you don't want to find out, which is you're not as good as you thought you were. And but the beauty of it is and what you had intended in other systems of care is you have the ability to surround practitioners with a supportive environment that says, you know, you're having a problem with revisions on your total knee surgeries. You know, your revision rate's too high. Let's look at what you do and what others do. And so that culture of learning and so embracing measurement and then the transparency of comparison and learning that is not overnight. That is not something you just plug in youth development agenda over years. And so guys are so well, people say Kaiser is great, Kaiser is very, very good. But it was not good 20 years ago and it was not as good ten years ago because of embracing that notion of we know where we're going to go, we're going to measure some of things we're learning, we're here with each other. And that's very challenging. You know, physicians, like a lot of professions, are very highly skilled and very accustomed to being notable and bright and, you know, templates and all that. And it's not natural or easy to necessarily what could bring me on the ten things I'm doing poorly or doing below average or doing that sort of thing. You know, we've all been in that curve. You know, we got to make age and chemistry. And so this lifelong learning is really enhanced by being in a system like a medical group or a system of care. It's very hard to do that in solo individual practices. Dr. Faisel Syed [00:13:56] Mm-hmm. Dr. Jack Cochran [00:13:58] Yeah. So the question about the automatic health record, I'm not used to big implementations. One is when I was still in private practice, still in practice at Kaiser, we went from no record to a long designed IBM record, which was very it was very basic and had lots of lots of limitations. But after we got all of our acquisitions on it and by the way, it was like day and I wasn't in leadership then. I was probably one of the cynics out there, but even physicians and I will reference, you know, your doctors like myself who weren't necessarily computer literate or computer facile, and we're actually a little bit embarrassed to go through the implementation because they exposed that limitation. I did even that group, if you said, okay, it's a year later, we'll take the computer away if you don't like it, they would lay in front of their door and say, No, you can't have it. And that was because they really learned that the readily available access to data and information and prior notes was so much better than the computer that they had used before. And, you know, I talk about the you know, the authors visit 1.0, which is doctor, nurse and patient, and this was the computer and the record was a paper chart, which is very risky. And then once we got into the implementation of the system, we had new problems. We we'll start new opportunities and new solutions. And our physicians really enjoyed that. They never thought the system was that good because it wasn't that good a system. And then the second implementation, I was still in the region at the time. We went from our IBM system to EPIC system to see what's going on in terms of Kaiser. And we already had a up and running culture of computer literate physicians. We went from IBM to EPIC 700 physicians, 17 clinics, 400,000 patients in audience. Dr. Faisel Syed [00:16:01] Wow. Dr. Jack Cochran [00:16:02] Wow. Four weeks, that is. That's a change management story that was worth listening to sometime, but it wasn't random. Lots of crap and it wasn't me being charming as lots of preparation, being very intentional and being very specific in how we did the change. Robert Longyear [00:16:20] Right? The EMR implementations that any organization is, is a big lesson in change management, and the folks that do those implementations are masters at change management and in project management and handling a whole bunch of contingencies at the same time. So yeah, I can appreciate. Dr. Jack Cochran [00:16:39] I mean, I love. Robert Longyear [00:16:40] Big scale. Dr. Jack Cochran [00:16:42] Again, sort of back to back a little bit to the notion of culture. Wouldn't it be great if what Basil said was universal? People around the world were saying, I believe that health care is a right and we want to, as an industry, as a profession, raise all boats and build this great opportunity for our patients. Because, after all, isn't that a real stakeholder here? And so we need to become more of a learning industry where I can learn from that and you can learn from Emory. And we just don't do that as openly or as well as we could. And so in a world where we have good data, we have good patient ID, we have good coding that has some rationale to it, and then we have interoperability and the agreements to share data. The upside is exciting, but we were just out there. We're on that journey. Dr. Faisel Syed [00:17:34] I love what you said about the change that you made in the way that you made that change happen so quickly. Four weeks in my residency training, we had a hybrid. We transition from paper charts to electronic records during my residency training in the hospital, but it was a hybrid. Our charting was done on paper and all the imaging and everything was scanned into the computer so we could search through previous notes. Still quite cumbersome, but it was a difficult transition. It was very hard for the physicians to go from writing their notes quickly, putting in the just the date. You put in a quick note, you put in some orders, and it was just it was clean and it worked to having to go through the computer. It was just that learning curve even. And this is just within the last 15 years was a big learning curve. Dr. Jack Cochran [00:18:31] Yeah. Well, and that was before today. We now understand and again, the learning curve is all over the map. Words for positions, the power of aggregated identified data that can be analyzed and put through algorithmic scrutiny and then come up with projections and I mean the use of AI and using data at a much different in a much different way is so exciting. And I think it will start to if we continue to learn smartly, start to deal with this dilemma we have, which is a health care system that has miracles and breakthroughs and cures, and yet high levels of quality issues and significant affordability issues. And that's on the patient side. And then on the doctor side, miraculous opportunities to deliver great care under the greatest care, the greatest care imaginable, and doctors being unhappy and miserable. And the facts are. Those two problems cannot be solved in series. We don't say, okay, we're going to solve the doctor problem, but that's why there's no way to work on that, because we've got to start thinking that the systems of care that we design have to serve all of those things. And who is more central to that than the patient and who has the most disproportionate impact on the patient but the physician? So I don't talk about physician leadership as we're more important than patients or nurses or anybody. No, but we have disproportionate impact and we have that impact. We've earned it. And we need to keep it because of trust. We have that trusting relationship that says to a patient, I trust your information, I trust you're going to be there for me, etc. I can help you manage through it because we have this great relationship. Same with nurses, the same with people around the hospital system. Physicians should be in the center of all those discussions you referenced in my book. If either leader partner well, start the non book before that were two physician traits that I saw regularly that I thought were completely disturbing and dysfunctional. One is physician as victim position is victim. Size lines and references, all the external things that are wrong, that are the reason the things aren't good. And even though many of those things are truly wrong. Once you take the role of victim, you become helpless and patients don't need helpless doctors. So that's position as victim. The second role that doesn't work, although it can get the job done, is physician as tyrant says, I'm in charge. I got the big degree. We're doing it my way. Let's go. You know, if you just cut across the aorta, that's probably okay. But that's a very unhelpful role. So I came to heal our leader because I realized as healthcare became more complex, I was trained in the healer. How do you do? Good care, good surgery, make sure you're doing things well, develop the trust, develop the skills, and then all these other things were going on in the world about affordability and access and all these other things. And nurses are unhappy. And and so I said. Is it is it legitimate for me to not hide inside the healer role, but to take the healer role as that's my watch. That's all I'm into when these other things are going. Patients in the health care system. Physically, socially, psychologically, financially, we can't lean in and lean out. And so the role of leader says. I have to have some accountability around affordability. I have to have some responsibility because our patients, whether they have good insurance or no insurance or whatever. Or rationing health care at the kitchen table. Dr. Faisel Syed [00:22:49] Yep. Dr. Jack Cochran [00:22:50] They are sitting there and saying, you know, we got a $5,000 deductible this year and Johnny needs his tonsils out. But the clutch just went out in my truck. This month. We've got to get the truck fixed because I got to get to work. Patients are rationing health care. And we can say to us, those companies, it's the pharmaceutical. That's position as position as leader says, I better lean in. I don't have to become as smart as the finance guys or the operations of the. I better have my good clinician and my learning have to say, how can I participate in that conversation? And then position is partner. Wakes up to the fact that this is truly a team sport and the idea of health care Team one at one point, which is doctor, nurse and patient and I'm the one and I'm the guy and I got the computer. Too much complexity knowledge just as exploded technologies is where all these things have exploded and every athlete has gotten more, more knowledge and more complexity. You can't just say it's all got to go through me. You got to learn how to work differently and better with nurses and pharmacists and special subspecialists, etc.. But I'll close by saying the final thought that I developed in the last five years that is really a little bit out there is because people I go back, a physician is becoming aware that things would be okay here in Tampa if it wasn't for those suits and those are that the finance guys on the second floor or those geeks, those are the guys on the third floor. Guess what? Those two specialties are on the health care team. They are on the health care team. They work in health care. They work for health care organizations. They're trying to solve health care problems. And if our attitude is you're bad, you're over there, or you're just over there, whether you're good or bad. And I'm we're doing the Lord's work, right? That's right. You look at the world and the real partners not to be the tyrant, but to say, no, I am humble. I don't know what's going on. But let me tell you something. When you said that about how you saw a computer system at work, I need to give you a little bit of my point of view, because I think you may didn't design a perfect computer system that's going to make doctors and patients crazy, and they're not trying to do something sinister. They're just trying to do their jobs. So this is not a leader that says, I'm going to be around and don't say, you know, those finance guys, remember, portability is their responsibility. Let's go back to trust. $0.83 of every dollar spent on health care delivery. And the core of that is the trusting conversation between doctors and patients. That's where that $0.83 gets. Dr. Faisel Syed [00:25:43] You know, it's like it's almost like, you know, that's a transition happen. We switched to electronic medical records and then suddenly also the doctors had to justify billing codes. Level three, level four, level five. So now you had doctors who had to learn this new medium. They had to start putting fluff in the chart to justify different levels of billing and the people the targets of our frustration or the i.t folks and the finance folks when it wasn't either their fault the i.t folks were just trying to build something that would help us do what we needed to do. And the finance folks were just working within the fee for service system. Yeah. I wonder what would have happened had we not had that fee for service model if we had more of a value based model where the doctors are more focused on the assessment and plans, more simplified documentation, I wonder if that transition would have been better. But I guess now it's neither here nor there. Dr. Jack Cochran [00:26:42] Well, a lot of our colleagues that we train with, whether it was in school or in residency, they weren't bad people, they weren't immoral, they weren't evil people. But you dropped them into a fee for service system. And they're not only clinicians, they're also breadwinners and fathers and husbands. And, you know, they've got to figure out how to run the business, too. And there's a there's a lot of gray areas in the fee for service model. And it's a very it's a very tough model to exert all the things that you should as a value based clinician, etc.. And so, yeah, I think it's a very flawed model. I think that some some level of prepayment and value based is where we need to go. It it seems to be very hard to do and very slow. But right now the amount of wealth transfer in our country, not only with families rationing at the kitchen table, but employers deciding between, you know, raises in their salaries versus health care benefits, governments deciding how to ration health care. It's not it's not yesterday's or today's problem. It's it's all around us. And I think that. I was very disappointed that the Warren Buffett, Jeff Bezos and Jeremy Diamond didn't see whether the two of the one day I thought they were going to really lead him to something. But it's tough. It's tough because the reason health care is tough is a little bit theoretical, but there are simple problems, complicated problems and complex problems or simple problems. You've got a sore throat, you have a strip was if you get a prescription to be done algorithmically a complicated problem, maybe doing an operation if you get the right diagnosis, the right team in the right venue. And then there's a complex problem, which is the health care system. And the problem with that is it doesn't lend itself to somebody being in charge in a linear progression of things because you can do a great job of solving health care needs. And if you've left out the pharmaceutical industry, you're not going to get where you need to go. Or if you've left off, the doctors left. And so the reason the complex problems are tough is because it takes the patients to collaborate and to listen and to take people with disparate views and have the courage to roll up your sleeves and say, we're not leaving until we find ways that we can get the best solution, because we'll never get our solution or a perfect solution. Robert Longyear [00:29:22] Dr. Cochran, One of the points I think you made that is very important is that in the United States, we don't even have full health care coverage. There's still at any given time, 8 to 10% of the population is over the past 15 years that has not had access to or health care coverage. So, you know, that's where you do get a lot of people who are making rationing health care decisions at the at the kitchen table. And, you know, we even in the United States haven't even solved that basic problem. And that alone is something that is it says something about the the amount of effort from a high level that's being put in to really rethinking and caring about the US health care system. Dr. Jack Cochran [00:30:01] You can imagine what it did to me the number of times, because I've spent a lot of time with it in the international world talking to health ministers, etc. But I've sort of been around because of the Kaiser job. You can imagine how it was very, very embarrassing for me to answer the question. So why do Americans think health care is a right? Why don't you think doctors are right? To the richest country in the world, we think our are right. Why don't you think about this? Right. So that's a that's a very interesting issue, isn't it? And yet everybody says. Well, the British system is flawed and the Canadian systems flaws. You know, they all have their strengths and weaknesses. There there is not a perfect system. But again, physicians who embrace being healers, leaders and partners can take this seriously and start to be in a different leadership role, have different relationships with the finance people and the people of different relationships. I know it's idealistic, but if I was not an idealist, I wouldn't have the energy to continue to push some of that stuff because my grandson needs a good health care system. Okay. Right. That's that's. Robert Longyear [00:31:17] Right. Dr. Jack Cochran [00:31:18] That's important. Robert Longyear [00:31:19] I can't understand that. It is like American. Like. Like there is this feeling that they don't really they don't want socialized health care. They don't want single payer health care. We but when you go into the current system, like our people don't seem to ask themselves like, this is horrible, this is really bad. Could something be better than this? And it's it's always shocking to me that there's a lot of people who are like, I would much rather have what we have now. And I find that rather interesting because. Dr. Jack Cochran [00:31:50] Well, not. Robert Longyear [00:31:51] Without. Dr. Jack Cochran [00:31:52] Putting it together. If you spend much time in Great Britain, you will understand that the National Health Service is a source of tremendous pride to the British people, you know, free at the point of care, universally available to everyone. I mean, they're very proud of that. And then you say how that working as a patient and they go, oh, well, first, you know, we get big kids, we get this, and that's okay. I mean, it's very interesting. But, yeah, the you know, the American sense of independence and all that. I think the reason I like the fact that Warren Buffett got interested in health care is that even if you only care, if you only cared about the economy, you should care about health care, even if you didn't care about the ethics of access at all. I believe you only just care about the economy because, you know, the wealth transfer is non-trivial at the family level, at the community level, at the government level, at the corporate level, at the national level. And we could we use another 8% GDP on something else. Probably. Good. Robert Longyear [00:33:03] Yeah. I mean, just the fact that wages really haven't gone up and on par with inflation is largely attributable to increased health care inflation when employers and organizations have to devote more to that spend, as you brought up earlier. And you know, that's that is a big problem. And, you know, besides the fact that effective health care systems are produce healthier, happier people who are more productive and therefore more economically productive, that's beneficial. On top of the fact that wage growth has been stagnant because of health care costs as well, it's not good. It's not good for society. Dr. Jack Cochran [00:33:40] The other thing is that those other countries have a very strong primary care based health care system. And that's we have gotten very specialized. And then and then we've chosen to pick a at different levels based on subclasses. So we've done a lot of things that were sort of entrepreneurial and that sort of things. I would tell you, just parenthetically, I had an experience in about oh 8 to 10 or 11 where I worked, where I was the senior executive from Kaiser Permanente. I worked with Tony Curtis, who's the CEO of Mayo and a guy named Great Paulson, who's the CEO of Intermountain and our three teams. And we worked with five Democratic senators and five Republican senators led by Ron Wyden, Democrat from Oregon, and Bob Bennett, a Republican from Utah. And they worked together and they talked to each other and they lost. Lindsey Graham was one. And we developed something called the Healthy Americans Act, which is a sort of a competitor with Obamacare. And they worked together. That was less than a decade ago. I mean, the place has really gone crazy in the last year. They can't work together. And it wasn't just the white man, Bennett. We're masterful, but we roll up our sleeves together. Real problems, real issues. And just as chickens behind closed doors, it was a little hard to just, you know, go to CNN and or Fox News and blame all the other people. It was five and five. And they worked together. And we developed a bill. It wasn't it didn't get to it didn't get to the floor, but it was the Healthy Americans Act. Dr. Faisel Syed [00:35:18] You know, Dr. Cochran, I would love to talk with you about that in particular, not tonight, but at a future episode. I'd love for you. I'd love to hear your insights with how especially now with how polarized the country has become. I'd love to kind of tap into your brain to see that. How did you how were you able to make that happen? But before I and before tonight ends, I have. Dr. Jack Cochran [00:35:45] To say they were polarized. Let me just finish. That said, they were polarized ideologically in some ways, but they had a certain respect and a certain grace in dealing with each other. So Bennett and Bennett was very conservative and liberal. Very liberal. They would actually at times during these weekend sessions, they would start laughing at each other. They go, Yeah, I know what you're going to say or Bob, I know it here. They would laugh at each other's ideological difference. But the subplot to this is. As we got to the end of it, Bob Bennett was up for reelection in Utah and he was a banker, a grandfatherly, dignified, gray haired man and Mormon leader at his church. The Utah State Republican Caucus kicked him out. He did not get nominated for reelection. It was the Tea Party era. And they said it was because he was too chummy with Ron Wyden. Dr. Faisel Syed [00:36:50] Wow. Wow. Dr. Jack Cochran [00:36:53] I mean, the NYT and Lindsey Graham and a guy named Nelson from Florida and some others at the same table looking at data with us. And it was I thought it was easy. We went to Senate Finance. I got to testify at Senate Finance one day, and at the end of it, this youngish middle aged woman senator comes up to me and starts asking me questions. And I don't think either anybody in health care there ask me more discerning, more specific, more targeted questions. And I said, Who is that? I said, It's Senator Klobuchar from Minnesota. She was really she was on her edges. She knew what she was talking about. I didn't know her. Dr. Faisel Syed [00:37:37] Well, Dr. Cochran, we're going to take a quick 15 second commercial break from Chen Med. So and when we come back, I'd like to ask you some questions specifically around physician leadership with steps that doctors can take to feel more empowered. I love what you said about doctors not being feeling like the victim and acting like the victim. Doctors being more savvy. So I want to ask you one or two more questions when we come back from our commercial break, specifically around physician leadership. Before we go on to the commercial, I just wanted to. Chen Med is to announce that Chen Med is growing. We currently have centers in ten states. We are opening in Texas and Michigan. This year we'll be in 12 states. We're on track to open another 500 plus centers over the next 4 to 5 years. Incredible growth. And we need doctors, we need nurses. We need people to help us with expanding our full risk, value based care model. Our centers exist in underserved communities across the country. Earlier today, I myself was in North Tampa administering the COVID vaccine to to underserved patients. It's not an issue with the underserved community of vaccine hesitancy alone. It's about access. And so please take a listen to our commercial from Chen Matt, and we should be back in about 15 seconds to wrap it up with Dr. Cochran about some questions specifically regarding advice for doctors interested in pursuing professional. Ad Break [00:39:13] ChenMed honors seniors with affordable top of the line care. And we're expanding. We're opening 25 new centers this year, including centers in two new cities, Houston and Detroit. Join us as we bring better health care to more seniors. Head to chenmed.com/physicians for more information. Robert Longyear [00:39:34] I don't know when you guys are coming to DC, but I didn't see a dog on there and I'm looking forward to it. Dr. Faisel Syed [00:39:41] It's definitely not a question of if it's just one, I promise. Excellent. Okay. Well, Doctor, Dr. Cochran, it's going to be very hard for me to call you Jack. Ask Dr. Dan. He's been saying for a couple of years now, and he's forever Dr. Dan's for me and my children. It's out of respect. Dr. Jack Cochran [00:40:01] I always joke with Eli and say, Well, that's okay. But if you get if you meet me on an airplane, don't say hi, Jack. Don't know. Dr. Faisel Syed [00:40:13] What. Dr. Jack Cochran [00:40:13] Jack you're thinking. Dr. Faisel Syed [00:40:16] But you've been an advocate for physician leadership now for years. What would you say motivates physicians to keep moving forward in this health care delivery system that doesn't support them? Dr. Jack Cochran [00:40:30] Well, I think that we have choices. Things are things are tough. Things are tough for patients and tough for doctors, nurses, etc. And we can take the choice of the victim and tyrant, or we can say, no, I can't do that. I've got to lean in and I've got to find somewhere. Now, that doesn't mean you say, okay, I'm going to be a CEO of something tomorrow or I'm going to be the dean of something. It says I'm going to embrace the sense of accountability, that I am going to be a leader. It is not something that you do by declaration. It's a commitment. And you volunteer, you learn, you seek to learn. You seek people out like you or me and say, how did you do it? What does it look like? How do you learn? Because the problem with medicine, it's like engineering or everything. We are so programed to live and die on individual competence and academic prowess that we got to be the smartest dude in the room or we're in trouble. And leadership ain't that way. Leadership is messy and leadership is about I care about this. I don't know exactly what's going on, but I'd like to I'd like to speak up and I'd like to hear your point of view. I say that. Leadership in one sentence is something like. Leadership is a process of listening to somebody else, acknowledging what they have to say, challenging their words, adding your words, and to begin to co-create understanding and co-create knowledge and co-create a bigger sense of reality so that you can then start to co-create solutions that you can test and work on together. It is not a fast process done by geniuses overpowering other geniuses. It's a it's an iterative process of listening, acknowledging technology to co-create realities because. One of the things I say in my second quarter is so true. I call it the cross. And the crux is look at yourself, look in the mirror. What kind of a what are your beliefs? If you believe that your fellow man or woman, your fellow colleague is sort of, you know, they're kind of out for their own good, they're sort of selfish and they're sort of, you know, they're just kind of they're in it for them, if that's how you believe. And you're going to have to have a communication with them, what are the tools you use? What you probably use manipulation to force them. You know, they're not going to go along with it anyway. So how do I trick them or manipulate them into a point of view? If that's how you think of your fellow man, if you think of your fellow man as somebody who's, you know, pretty reasonable and pretty open, you approach them differently. Your person would listen acknowledging, understanding their point of view, building on that to start to co-create a basic knowledge. It's a little slow, it's a little slower. But I'll tell you what you find. Over time. And you've got to be a team that's in leadership training. You got to you know, you got to do those things and you've got to be in a structure that is perfect. It's a structure. You can take your budget and say, we're going to invest a certain amount of money in doctors, be in leadership roles, and, you know, the fee serve those as well. That's you know, that's what's funny. You're not in a hurry. You know, that's a mindset and on assumptions that I long ago got rid of. But you invest in people being leaders, so you invest in their training, their development. You give them time to give them support. So you start to say, we're going to develop leaders and we have this I call it the coalition of courageous colleagues. Yes, I've been working with a group of people from Australia for about six years, and it's a completely random process where I met a few friends, they met a few friends and there's about 60 out of there, mostly GP and I get together with them on the phone and print, but it's so funny because I'll be talking to them. We'll be doing a Zoom call with them and say, Oh, Jack said in Sydney in 2006, and I go, Oh really? But the Coalition of Courageous Colleagues says it's not weird to do it to do so. It's not it's not weird to be a leader. It's not weird to be partner. It's not weird to do what I do and help each other and learn from each other in the same organization as leaders. We didn't always get along on things. We disagreed on certain things. But, you know, I think that physician leadership is not the only answer, but every time we opt out. The patient loses a voice. And we've got to develop and we've got to pay attention to careers. This notion of the burnout and the physician career, I took this seriously in 1999. If you read the first one, I said, Our doctors are not overworked, they're frustrated, they're not getting the kind of support they need. They're not. The computer was wacky and then the support them, the team development, they weren't overworked. Doctors were used to working hard. But you take somebody who used to work 80 hours a week, you know, 15 hour week job and they're unhappy and burned out. Something's going on. And we've got to approach the career issue just like any other scientific issue. What's the hypothesis? What data are we going to gather? What are we learning? Are we to learn from each other, from our coalition of specialty groups? And then how are we going to progress and work together? The career issues are not insoluble. They can be solved. But we've got to acknowledge it's a problem and work together on trying to solve it. And it's not just about more money or less time. It's it's where we are hard working professionals. It's an honorable craft we need to honor. When I made physician career my first priority in 1999. My language was reservation an enhancement of career because I got burned out, crabby and not overworked. I said, This is a bad situation. And so I never said protect them or give them what they want. I said, preservation of their career. And my frame of reference was what? This is an honorable profession. And I know every one of these men and women at some level, and I know this they may be crabby at 45 or crabby at 55 or checked out at 70. When they were 21, they were applying to school and they had to write a paragraph in that little application. Go back and read those paragraphs. That was a 21 year old idealists teeming with energy, enthusiasm, brains. That person didn't die between the system and how they reacted to the system with everything else. The system has taken its toll. That person is not dead. And there are still people out there that are still very happy, stronger, and so probably more intense than they are down the street because they're small. Dr. Faisel Syed [00:48:02] And you know. Dr. Jack Cochran [00:48:04] The standard, you know, that's Robbie. Group doctors tend to be out here. Dr. Faisel Syed [00:48:09] It's true. It's true. I mean. Dr. Jack Cochran [00:48:11] It's dirty, you know? Dr. Faisel Syed [00:48:13] Yeah. I mean, we definitely do have our share of burnout as well. It's not that we're void, and our share of burnout is from the PTSD, from fee for service doctors feeling the need to still fill in the fluff in that chart. It's like we have to reprogram the doctors to find that balance with making the shift from the patient's chief complaint, which is like the MinuteClinic visit to the doctor's primary concern of the condition that's going to end up causing them to need to see a specialist or if it's not checked or end up in the hospital or the emergency room. Dr. Jack Cochran [00:48:48] I remember one time and this is antiquated data and probably didn't apply. And I'm a surgeon. I wasn't a dermatologist, but a dermatologist friend of mine said he said, go look at dermatology bills. And he says, you look at ten dermatology bills and you can tell me what the Medicare legislation says. And what it says is every dermatology bill, the doctor froze or treat her scraped three lesions or something like that. And the reason is Medicare pays 100% for the first lesion, 75% for the first lesion, secondly 50% for the third lesion and 20% for every legion after that. So the way you manage that is you do three and bring them back. You do three and bring them back. And you know, programing, programing, waste. Dr. Faisel Syed [00:49:36] Yeah, Well, I guess that's part of the reason why 80% of the doctors are specialists and we have 200,000 primary care doctors, 800,000 specialists in America. And it's all lopsided. It's all lopsided. Every aspect of it is lopsided. I love what you said about leadership. Dr. Jack Cochran [00:49:56] There is no study I've seen or no evidence in the world that doesn't say. The best health system outcomes are when you have a strong primary care base that that has been proven over and over and over again and this world of complexity. The first wave of complexity was more knowledge, more information. The heart used to be heard by the cardiologists. Then you got an interventionist, you know, a muscle doctor and a valve doctor and a doctor, and you got all these vessels and that was driving more subspecialty specialization. But the second wave of complexity brings primary care right back to the center. And I so I say the first wave of complexity where we have more and more knowledge and more depth in every organ, maybe specialty care, more primary, you got your heart problem, you went to your cardiologist and they took care of it. But the second wave of complexity is multi, multi morbid patient, multi co-morbidities, which is we got your heart, you're under control, but now you've got asthma or you've got depression or you've got, you know, something you're creating, it's going up. Subspecialists are not training to manage multiple co-morbidities. And so the second wave of complexity, which is what we're all about, this world says there has to be a strong primary care team right at the center of this so that the specialists can and say, we know who's in charge of what's going on, which is the patient and their doctor. The second wave of complexity, there's multiple co-morbidity. I say the first one is that the first related complexity be specialty care more primary. The second wave of complexity makes primary care more special, have to have more primary care to take care of this multiple. Well, it really doesn't mean you getting smarter as a primary care doc in cardiology and nephrology, it means you're in charge with that patient of good thinking, good, trusted decision and holding a specialist accountable. And that's the team. Dr. Faisel Syed [00:52:02] Dr. Cochran, I have to bring you back. We are approaching an hour and I asked you to come join us for a half an hour. I have many more questions for you. Many, many more questions, especially around the primary care that's being delivered by specialists. You know, I know I hear about neurologists getting headache referrals and orthopedic surgeons getting low back pains and things like that. So really, I would love to be able to talk with you more about the ideal structure and culture for like the ideal primary care delivery system. And I have some more questions about physician leadership, but we are literally approaching an hour. I feel terrible that we've got this long. We didn't get to take any questions from the audience. Dr. Jack Cochran [00:52:48] So if so, I didn't feel bad about it until you just said that. Now I feel bad about it. I'm going to insist that you doubled my honorarium. There we go. Dr. Faisel Syed [00:52:59] There you go. We'll do it. We'll definitely do it. We will definitely do that. Dr. Jack Cochran [00:53:05] I listen, I go back to the belief in the coalition of courageous colleagues. I never run out of energy to help and work with and encourage and mentor people who are trying to do the right things. I just never I never run out of gas for that, ever. I ran out of knees. I'll be back when I'm back on Tuesdays. Pretty soon. I'm doing actually very well and I'm walking without a cane. Although I look a little bit like an old guy when I walk. But I'm right. And I'm doing well. I'm happy to know you and both of you and your teams are happy to do this again. Do more of it. It's a meaningful to me. You know, when I left BP, I said it was time, time to move on to something else. But I said I still got, you know, kids, grandkids, friends. This health care system still needs good, strong physician leadership, not tyrants, not victims. And I think I've got something to share. Dr. Faisel Syed [00:54:03] You definitely do. You definitely hear that. We can bring you back. Dr. Jack Cochran [00:54:07] Well. Dr. Faisel Syed [00:54:07] Well, Robert, what an evening with Dr. Jack Cochran. Dr. Dan, what an evening. Absolutely. Absolutely. A great discussion. And to our audience, I want to apologize for not being able to take any questions tonight. We just went over. I promise what we'll do, we'll bring Dr. Cochran back. Well, we'll announce it. We'll give at least a couple of weeks notice. Please leave your questions for us. We'll get them over to Dr. Cochran. We'll bring them back. He has a lot of knowledge, a lot of insight to share. It was such a pleasure to hear someone like him share his life experience. It's just it was a pleasure, an absolute pleasure. Thank you so much, Dr. Cochran. Dr. Jack Cochran [00:54:48] Thanks. Let's spend the evening with you guys. Take good care. Dr. Faisel Syed [00:54:51] And to all of our audience, thank you so much for joining us tonight. For more information about tonight's topic and to explore career opportunities with ten men, please visit chenmed.com. We believe access to primary care is a right, not a privilege.