Latest / Faisel and Friends: A Primary Care Podcast / Bonus: The Sacred Doctor-Patient Relationship w/ Dr. Jon Hart
Transcript
- Dr. Faisel Syed [00:00:12] 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 life? The current fee for service system health care is rationed out based on the patient's ability to pay. I believe it's unethical. This premium 95% of the country still functioning in this model. I definitely believe everyone should be treated the same and everyone should have access to primary care regardless of their ability to pay. Hi, I'm Dr. Fast and Fred. Welcome to another episode of Special and Friends. We're here because we believe everyone deserves access to quality primary care, and Chen Med needs physicians to take care of them. Today's topic is the sacred doctor-patient relationship. The doctor-patient relationship used to be a sacred one before it became the financial one that we all know today. Before it became this transactional reaction reactive form of medicine. Today, Robert can't join us. Robert, Hope everything's okay and I look forward to having you back again, hopefully, next week. Dr. Dan. Dr. Dan McCarter [00:01:36] Hey Faisel, I'm great. I'm great. How are you this evening? Dr. Faisel Syed [00:01:42] I'm good. I'm glad you're here. I was worried that you may or may not be able to join because of the weather situation in Richmond. Dr. Dan McCarter [00:01:52] That's right. That's right. Have a little bit of ice, but that's okay. I. I will stay inside. It's a good night to be inside with you. Dr. Faisel Syed [00:02:00] Oh, it's great. And this topic is a topic that that we often talk about when we're just talking shop about the nonsense that patients have to go through and not even the medically complex. I mean, that's that is in itself, you know, unforgivable. What patients with actual chronic medical conditions have to go through in their trying to navigate through their complicated health care delivery system. But even people who just need a physical, a checkup, how difficult it is to go just get basic checkups done. This week's friend is someone I'm really excited to have. Come on. Dr. John Hart. Dr. Hart. Dr. Jon Hart [00:02:46] Hey, Faisal. Hi, Dr. Dan. Dr. Faisel Syed [00:02:48] How are you doing tonight? Dr. Jon Hart [00:02:49] Doing well. Doing well. Much warmer than it is up there in Virginia for Dr. Dan, that's for sure. Dr. Faisel Syed [00:02:56] And you're in South Florida, right? Dr. Jon Hart [00:02:58] I'm just probably 100 miles south of you in Fort Myers. Yeah. Dr. Faisel Syed [00:03:02] Oh, my God. That's great. I had the pool heater on earlier, and my kids and my father are all in the pool right now as we as we speak, just enjoying the weather in Florida. But, Dr. Hart, you know, I wanted to ask you about your book value in health care and what was it what were somewhat was the main driver? If you had to pick the main one or two drivers for you to write this book, what was it? And where do you feel like you are now? Dr. Jon Hart [00:03:40] Yeah, well, that's a great question. Fassel. I think the, the, the couple of things that really drove me to write that book were looking in on and working in the health care arena where, you know, for the last 40, 50 years we've been steeped in a volume-based fee for service model of health care. And I had learned a different way of doing that when I actually when working for a health insurance company, believe it or not. And and and the we called that system value-based health care. But it's basically a different approach to how we take care of folks instead of just sort of the churn and burn having cogs in the machine producing widgets and selling a service for a specific price for how much quantity we can make of it. It's really about creating value by having the best quality at the at the appropriate cost while giving everybody involved in the the experience that was needed and beyond the financial part of that, I was intrigued by the interpersonal part that really makes value based care successful and sets it apart from volume based care. So those were the two things that got me started. And then, you know, I was reading Atul Gawande, his book Better, and it got me so excited about the whole concept of how we can it's not a value based care book, but it's it's focus on how can we do health care better. And in it, he says, and I quote this in my book, but he says, you know, in the work against sickness, we begin now with genetic or cellular interactions, but we're human ones. And I would add to that that also we don't begin with solely technical or technologic connections either and the whole key and one of the premises of. Value based care, and I try to point this out in the book, is that the key is an appropriate application of relationship and technology. Certainly there are things that we can do and should do in today's world with the amount of data we can aggregate and analyze and know things about people even sometimes before they know it. But if we don't have that relationship with the patient and we don't continue to have a relationship with the patient, then they miss out on it, on really good care. They don't feel cared for. We don't learn everything we need to know about the patient because you can't find everything in a discrete field of data. Dr. Faisel Syed [00:06:32] You know that the interactions not only between the doctors and the patients have become transactional. The patients feel it, too. The patients feel like the doctor is being rushed. The doctor is more concerned about typing on the computer. The doctor's distracted with the phone call or a text message. They feel it, too. You know, they feel that this system has become this way, but they've got to fight for what they think is in their best interests. Dr. Jon Hart [00:07:07] Well, one of the whole I dedicate a whole chapter in the book, actually. It's called The Real Values in Value. And what I what I'm talking about with that is that when you think about the volume model in the volume equation, which is quantity times price, you know, that's that's what it is. Quality and experience aren't contemplated at all. And so when you approach something like that again, where it's just in the medicine vernacular, street and street train and burn whatever you want to call it, when you approach it like that, the you don't you being the system, the health care system does not value the components of health care. We don't value then the patients, we don't consider them humans, we consider them widgets. We don't value the staff or the physicians or the providers. We consider them cogs in the machine. And so that's one of the beauties of value based care, is because we consider quality and experience, we have to value all the human element for truly what they are, and that is humans and worthy of what we have to offer. Dr. Faisel Syed [00:08:26] Someone. Someone asked me. We had a social last night. Was it last night, Dr. Dan? What was it that someone asked about the difference between HMO as capitated medicine from 1991 compared to what the world is like now today in capitated medicine in 2021? What would you say the main couple of differences are? Dr. Jon Hart [00:08:52] Yeah, I think there's a there's a few. And I think the folks that set out on the HMO journey had the right thing in mind. I mean, Mr. Kaiser, when he developed the health care program, onsite health care program for his folks in the shipyards in California, he had the right idea. And that's partly why Kaiser Permanente, his was the one I mean, one of the few that survived the nineties and made it into this century. But I think the big difference between what we're trying to do now and the HMOs, that most of which ended up failing, is that we truly have the ability and I spoke of it before, but it's that ability to aggregate a lot of data and look at it and to be able to risk stratify patients to know who needs our attention most so that we can then apply resources to them to optimize their health and well-being. What happened in the nineties, because we had paper charts and the you know, we had the data, it was just in stacks and stacks of paper and who could go through it. So what ended up happening, happening with most of the HMOs is feeling the pressure to decrease cost without having the ability to truly analyze and and do the basics of population health management risk stratify, make a plan of care, and then longitudinally support those folks. They just went for care rationing and decided we're just going to cut costs by saying, no, you can't have that. And people didn't get along with that at all. And I think that's why it failed. And that's I think the key difference is that we now have that ability to take those stacks and stacks of data and information and make something useful out of it. Dr. Faisel Syed [00:10:43] You know, Dr. Dan, in 1990, you switched your office to electronic health record, so you had the EMR in 1990. I want to know, what was that like making that switch and what was your relationship like with your patients, Like with the paper charts at the time of the paper charts, the relationship with the patients and your relationship with the emergency room doctors? And did you admit your own patients? I want to know what that was like, because what I'm trying to get at here is do we? Yes. The data obviously helps. You know, of course, technology helps. It's an it is an extension of us and it makes our lives so much more efficient. But at that time, I have this kind of view of medicine from at least in the eighties of doctors really knowing each other well, knowing their patients well. If your patient went to the emergency room, the emergency room doctor or somebody would let their primary care doctor know. I kind of would like some insight around what that was like. Dr. Dan McCarter [00:11:49] Well, I again, I you know, I was at the University of Virginia then and there wasn't there there was a very nice emergency room, but the emergency medicine department was really in its infancy. And so it was basically people were managing their own patients if they went to the emergency room. I would have to call one of the family medicine residents who was because I was part of the Department of Family Medicine, and they would go over to the emergency room and see the patient. And if the patient needed to get admitted, they would admit the patient to the hospital. And then certainly whenever they came back and I would do my turn on the inpatient service and on the call. So, yeah, we admitted our own patients. I mean, you said I put in an EMR. Well, I did, but you got to understand that was before the Internet. So I had an EMR that was not connected to anything. It was connected to. It was basically a way to keep records in the office. And it could give you reminders, you know, on you could have alerts when people needed flu shots and stuff like that. But as far as being tied to what was going on out in the real world, yeah, you still had to pick up. You had to pick up the telephone. And still one of the best pieces of technology I had was a fax machine. I thought I was in high cotton because I was able to buy a fax machine. And if a patient showed up to see me with chest pain and they had been in the emergency room, I could call the E.R. and they could pull it out of their database and they could fax it to me. And I had an EKG to look at. So it wasn't a downer rich environment. But, you know, I want to say one more thing about that. I'd be interested in what John thinks. I feel like when RV use first came out, the idea was the RV you was going to be a byproduct of the care provided and it was just a way to pay the bills for what was being done. And somewhere along the way it got perverted to where what we're trying to produce is RV use, not trying to produce health. And I think that's where things went askew. And I don't know how we get back to paying for health rather than paying for RV use. Dr. Jon Hart [00:14:06] You know, I totally I totally agree with you. Dan and I had one of those AMA's too hooked up to the Internet in the nineties. And you know and I think it's key, a key point to make about a change in medicine. And I don't want to sound like the guy who used to walk up to the hospital and snow eight miles both ways. But you know, we did communicate with physicians, with other physicians who took care of our patients. If you were going to send somebody to any kind of zoologist, you would dictate a letter or call them on the phone. And lo and behold, when they saw that patient, they would call you on the phone or it wasn't particularly urgent, send you a letter back and you actually knew what was going on. But in terms of RV use, so, you know, a relative value unit, I think you're right. It started out for the right reason and it had the name. It has value as its middle name. It's really, I think, morphed into a relative volume unit and it became a tool of production and tools of production work really well in a volume model. And so I think one of the ways that we can get away from, you know, running on the hamster wheel of fee for service medicine is to stop linking compensation to the productivity of relative value units and start thinking more about truly, you know, member-based. And if you want to use the term capitation, fine, but member-based per member per month payments mean that direct primary care is based on that principle, unfortunately. So it's concierge medicine and that's why I were talking the other day about how those unfortunately have gotten melded together. But I think that's that's some of the some of the ways of getting away from that. Dr. Faisel Syed [00:16:07] You know, we should just call the review what the overview is. It's reverse value. It is the reverse value unit. Yes. You know, a good direction to go in is that the higher the RB to the lower the. Yeah. Dr. Jon Hart [00:16:23] Well it's one of those things too. So you know, a family doctor, a general internist can spend 4550 minutes with a patient and generate I think now it's three, it used to be two around three RB use or an ophthalmologist can spend 5 minutes with a patient plucking out a cataract and have 12 hours of use. So the math just. Doesn't add up. And, you know, and I don't want to go down the debate of, well, the technology and the training of the ophthalmologists or justifies the cost. There's certainly there's certainly justifiable cost in procedures. But tying it to these reviews is is not something I think is good. I found I wanted to share something with you guys that. Yeah, I find I finally took some files from home to my office this week and my wife is thrilled. But as I was unloading them and stacking them in my file cabinet, I came across an article I'd saved from Arthur Kleinman from Harvard. He wrote this in 2012 for The Lancet, and it's called Is the Art of Medicine. Caregiving is a moral experience. And I just want to read this part to you verbatim, because it really speaks to what we're trying to get at. And the general premise of this introduction is that, you know, there are things that money can't buy. And he said many clinicians reflecting on what's at stake in health care, not not only for patients but for themselves. No, the same thing. The market has an important role in health care financing and health systems reform, but it should not reach into those quintessential ills of caregiving that speak to what is most deeply human in medicine and in living. This is the moral limit of an economic paradigm, or at least it should be. And he goes on to say that the imperative that economic rationality gives to us on costs and maintaining efficiency have muted the moral and emotional and religious and esthetic expression expressions of patients and caregivers. And I would go on to add to that. Instead of assisting us in our caregiving, we've allowed the incorporation of technology to participate in that meeting as well, especially when it comes to discrete field data collection or in diagnostic test testing. There are doctors today that, in addition to not having a converse of a relationship with their patients, don't even touch their patients. Dr. Faisel Syed [00:18:57] Oh. You know, when one of the one of the things I saw when I joined ChenMed, I joined Chen Med as a primary care doctor. And that and actually Dr. Dan and I were just talking about this earlier today or yesterday, one of our random conversations about the feeling of the doctor, the doctor patient relationship being restored with the full risk value based care model. And I was asking you about the earlier about the relationship that you that you all had in especially like in the late eighties and that time period before the Internet and before all this connectivity we had. Because when I joined the full risk model, suddenly the emergency room doctors were calling me, Hey, your patient is here. Or the hospitalist would call me. The specialists we have, we make partnerships with the specialists who have the best outcomes. And so when one of my patients is going to a specialist, I let specialists know if I have a question, I give them a call. And just that relationship that I feel like used to be. And I think about what medicine ought to be like. It ought to be this world where we're able to communicate with each other in that manner and even in the center to, for example, like I love, I love neath and doing the steroid injections and doing working on knees and in my center, the doctors, primary care doctors, the ones who weren't so comfortable with that would come with me. Learn how to do the learn what I did. We had this relationship and this camaraderie and I feel like that's the way it used to be, like. And I wonder I wonder, could we have a model similar to what we have without all the data and technology? Of course, now I'm with obviously Chen Med, one of Chen Meds companies, is an IT company C Tech. I mean we're we're actually more of an IT company when I think about this more we just happen to do primary care but we definitely feel more like a tech company when I look at all all the data that we crunch through. But what do you think? I mean, could we have a model like this? Could we? Is it really that simple? Dr. Jon Hart [00:21:13] I wasn't sure if you're asking me or Dan, but I'll jump in and hesitate. Yes, I think it is possible. And again, I think the good news is that technology actually affords us better opportunities to communicate with each others and each other as physicians than what we had when we had to pick up the phone. And hopefully, when I tried to call Dan, he wasn't in the room with a patient. But now we can we can communicate asynchronously and securely and or we can, you know, pop up, you know, if I need if I'm in a if I were in a room with a patient, I needed them to see Dr. Dan. I could pop him up on telemedicine. He could, you know, join in and we could have a conversation right there. So technology can really be an assistant, a valuable assistant in that, because if you're going to have a relationship with the patient, not only does the primary care doc have to initiate and nurture that relationship, but as you bring more people into the interdisciplinary team to take care of that patient, communication becomes even more important linchpin in that relationship. And so, you know, people talk about hyper segmentation in health care and boy, you know, wouldn't it be better if, if all if we could get everybody just to hyper specialize and and and take you know, everyone could have a specific doctor for a specific problem. And I don't think that's a bad thing. But we've been doing that for a hundred years. And what we've seen in the recent past is this separation in relationship between from physician to physician so that then the patient gets left in the middle to fend for themselves. Dr. Dan McCarter [00:22:55] Yeah, Well, and that would be sort of like trying to build a house. An analogy I use is you. When you build a house, you are almost always have to have a general contractor to do the construction. You don't just go out and hire an electrician and a, you know, electrician and a and a carpenter and a finished carpenter and a brick mason and tell them, Hey, I need a house at this location. Can you all show up and build it for me? Because it's it takes the coordination of care. And the interesting thing is if you've ever built a house is if you walk on a job, the suburbs won't talk to you if you're not with the general contractor, because the general contractor is the one that's coordinating everything. And they know they're just going to get in trouble if the client asks for something. Yet in health care, there's there is a lot of you know, a lot of in coordination taking place, a lot of waste and honestly a lot of harm that comes from that in coordination. But I don't know how we how we get to that get to that point that we that that. But I think, you know, the other thing is the contractor actually gets rewarded for the value of the finished product at the end. They're not just paid for their time standing there talking to the subs. They're actually paid for that for the final product. And I think that's what you're talking about. When you start talking about capitated payments for primary care, you're actually being rewarded for the finished product, the healthy days you're giving the patient. Dr. Jon Hart [00:24:35] Yeah. And I think though, I think philosophically, we need to be sure that we separate the financial aspects of a solid physician patient relationship from the personal and human aspects of that relationship. Because I, I do think, you know, if we can if we can think of the patient not as a disease, but as a person, then we're going to be more intentional about our communication not only to them, but then to anybody else that we engage on the team. And, you know, I quote a couple of different Williams in my book, and one was William Osler, and he said that, you know, a physician should care. Let's see if they care more, particularly for the individual patient, than for the special features of the disease. And then William Carlos Williams, who I love as a as poet, he said that, you know, people come to see a physician, not the people that come to see a physician are not merely hearts or livers or kidneys. They're a person with a unique problem. And frankly, we can't figure out we can't figure out what that unique problem is until we have that relationship and ask the questions. I see so many software platforms that try to say, well, we can we can tell you everything about this patient, including all of their social risks, based upon an analysis of the social determinants of health and their claims data and their pharmacy date and everything like that. But you know what? You may not know that. Mr. Jones doesn't have reliable transportation or a reliable food source until you actually ask him the question. And then to your point, then when I know that about Mr. Jones, I've been I'm going to take a whole lot more intention and effort in communicating things to the other people on the team so that they know Mr. Jones is a valued friend of mine. I have a relationship with him. I expect you to treat him the same way and you're going to keep me in the loop so that we can all do what's best for Mr. Jones. Dr. Dan McCarter [00:26:50] Well. And I think that that's the important part. I mean, one of my mentors coming along would say people want to know how much you care before they care how much you know. But, you know, I think different. I don't you think that the specialists, for the most part, they appreciate somebody who cares for the patient. And if they say the PCP has time to care and interact with them. They like being part of that as well. Dr. Jon Hart [00:27:21] They do. And the specialists that we bring into our preferred network with Millennium Physician Group, we encourage them to use our care management teams and social work teams. And our PCP is are supported by an interdisciplinary team around them so that the physician doesn't have to solve every problem. In fact, the physician may not even uncover every problem. But they know that they have somebody to help them with it. And I think to your point, Dan, that the specialists are thrilled if they know that, okay, if I send this patient back to Dr. Dan. He's going to help make sure that they can afford their medicine, that they're going to get it, and that if they can get to the next appointment and their housing is secure and, you know, so that they don't have to worry about that because they know that you're taking care of it. Dr. Faisel Syed [00:28:16] We have a question here. Could we put it up here? All right. From A-Z Kazmi. Thank you. So we have a question for Dr. Hart. How important is the doctor's attitude over expertise in the satisfaction of their patients? Dr. Jon Hart [00:28:34] Oh, I think it's huge. You know, when I was in residency and this was 30 years ago, there was a doctor in our hospital. He was a family dog. He still serves patients in the hospital, and this was a tertiary care center, and he had more patients in the community. But frankly, we all felt like he was a bad clinician in terms of, you know, the things that he did, but his patients loved him and would do anything that he thought they should do because he his attitude was one of. I'm present with you in the room. There's nothing more I care about than what's happening right now. And you're the most important person that I'm going to see today. And I'm going to make sure that I do everything in my power to help, you know, make you feel better. And so in a way, even though his clinical acumen was not necessarily where we as residents thought it should be, he was actually a pretty good doctor because of the attitude that he approached his patients with and the goodness he knew when to ask for help, too. And so that's sort of an extreme example. But then if you can take if you could take a doctor like Fassel who knows his stuff and then presents an attitude. Yeah, there you go. And presents an attitude of I'm present with you, I'm helping you feel cared for. You're the most important thing that's going on right now. Then that's going to be a successful interaction with the patient. And we also, you know, the medical literature for years has been saying that if you can if you can help allow a patient to feel cared for, your clinical outcomes are going to be better, too. So actually, you also get you're a better doctor in practice, too, because your patients do better. Dr. Faisel Syed [00:30:35] It's definitely much more fulfilling. It's definitely a much more fulfilling way to live your life. And I have an example, you know, and you're mentioning about the technology with a patient, a new patient visit I had as a telemedicine visit. So this was early on in COVID. We had just switched from, you know, our we see our patients on a monthly basis. The patient had a weekly phone call that we call a love call. They get a daily text message. Dr. Jon Hart [00:31:03] So I love that, by the way. Dr. Faisel Syed [00:31:04] It's a touch model, you know, and so and so we switched to telehealth and we have clinic and we're doing these telehealth and telemedicine visits. And this I had a 57-year-old. So we have a full-risk Medicare Advantage, but we have like 14 or 15% of our patients are under the age of 65, the dual eligibles, you know, And so I had a 57-year-old who a new patient visit at an alcohol treatment facility. And it was his first Tesla. It was his first face time. It was his first FaceTime type call. He never did. Had an experience like that before. So I thought, okay, it's to me interesting. I've never done this before. I never and I never have established a new patient at an alcohol treatment. Right. You know, But, you know, I went along and had the encounter and the patient was just so blown away that and I and I had my lab coat. I had my stethoscope around my neck, although I wasn't going to use it, you know, fell out with it. But but he was blown away that here I am establishing him and we're talking over this, you know, over the face. I call it face time, you know, but the telemedicine, Right. Yeah. And so we were just getting to know each other. You know, his right away, he started off saying, I need my Xanax, I need to refill my Xanax. And I had to go to the emergency room once a month because he struggles with homelessness, so he struggles with homelessness and his Xanax gets misplaced or it gets stolen. And he just started off the conversation saying that he needed his Xanax refilled. And then I heard him saying that how he had to go to the emergency room once every month to get a refilled. And I said, well, why do I have to go to emergency room once every month to get it refilled? He said, Well, the pharmacy gives me a 90 day supply at a time and because I misplace them so frequently, I have to wait the 90 days. So rather than waiting 90 days, I act myself and then I go to the emergency room until somebody will give me my Xanax. And I thought, boy. And then he said he said, You know the funny thing, doc, it's not even spelled Xanax. It's spelled Zoloft. And it's like, well, you know, and you know, it it is it's funny, but it's it's a reality of the world that we're in. Right. And I had to tell him I had to tell him that, hey, that's not Xanax that you're taking. That's like a you know, if you're taking like a blood pressure pill for your blood pressure, that is like a pill that you take for depression and anxiety. And actually, it was a very low dose Zoloft. It was like 25, I think, 25 milligrams. And the shock on his face, he said, You mean to tell me that's not Xanax? And I said, No, it's not sex. I told him, I said, Listen, if you ever lose your Zoloft or someone steals it, you just call me. Here's my cell phone number. I gave my cell phone number. I said, You call me and I'll buy it for you. It's one of those medicines that you can get for $10 for cash place from Wal-Mart for three months supply. I'll buy it for you. And you know what he said? He said, Darci, it. I don't want anything to happen to your medical license. He was worried about me. And now this is someone that we have two very different lives. And we're engaging for the first time like this. You know, with the video, we're not in person. And that doctor-patient relationship happened suddenly. Dr. Jon Hart [00:34:49] We treated him like a human. Dr. Faisel Syed [00:34:53] And now it's almost a year later. And he hasn't been to the emergency room since. Now, am I someone who knows by psychiatry or psych? No, I'm not an expert on psychiatry. Psychology. I know enough. But. But. But. But that's what I'm trying to say. It's not the pathophysiology. That's not what drives all the waste in America. It is this. It's that, like the patients who don't understand. I mean, if you look at the average 72-year-old, our average patient is 70 to 74 years old. That means that they graduated from high school in the 1960s. And if you look at 1970, that the percent of Americans who had a college education in 1970. Only 12% of Caucasian men had a college education, like a four-year college degree in 1970. And then the number drops in half for African-American males, and then it goes a little bit lower to white females and then to black females even lower than that. So, the population of patients that we have, we can't approach them thinking that just when you just think about health literacy alone, we can't approach talking with them as if we're talking to a medical student or nurse. Right. And and, and I feel that if we focus on the person. And we can reduce so much of the waste in the country just if we just focus on the human being that's sitting right in front of you, rather than having to be concerned about filling the fluff in the chart to get your nine, 9 to 1 whatever. Dr. Jon Hart [00:36:31] Mm. No, I totally agree with you. Absolutely. And, and, and you know, you talk about the waste, so your fellow that you've kept out of the emergency department for the last 11 months, you know, you saved probably the paper because I'm assuming he was a dual eligible you save the paper you know probably, you know somewhere between 12 and $20,000, which if we could do that in all the areas where we have the waste, you know, we'd have so much more money left over to take care of issues like homelessness and education and health care for people who don't have it. And it it it all comes back to. Are you going to create value when you have that conversation with the patient or are you just going to turn the volume out? And if we keep with a fee for service, I you know, I don't want to sound Chicken Little about it, but I think that's going to be the demise of our health care system. If we can't get the primary care docs to sort of lead the way into a value system that values the components of that system. And by that I mean the patients, the staff, the providers, everybody. And that we aim for quality, we aim for experience and appropriate cost. Without that, I do think it's going to implode. Dr. Faisel Syed [00:38:02] Oh, it's already the system itself and just the impact on society when I just I'm I'm appalled that the number one cause of bankruptcy in America is medical debt. And, you know, it's medical debt from the hospitals. It's not medical debt from the primary care doctor or from the, you know, the radiology place getting doing the mammogram. It's from these unnecessary hospitalizations. And just the amount of Americans were in debt collection, period. One in five Americans in debt collection because of medical billing. Dr. Jon Hart [00:38:34] And like like most problems, the solution is both simple and complex. Because, I mean, when we've been talking about talking about it like it's really simple to have this great communicative relationship with the patient and with other people on the interdisciplinary team and collaborate with all that, it's a very simple answer, but it's complex to carry out. And I do think that's where we need to rely on technology to help us bridge those, you know, some of those the gaps. But we still have to maintain the relationship with the patient. Dr. Faisel Syed [00:39:10] You know, and you'd think that with the elderly that they'd be opposed to telehealth, telemedicine. And they're not the case. That's not the case. I think I find so fascinating is is how you become part of a special group of people, because many of the seniors, they don't even face time, their own children, but they will face time, their grandchildren. Dr. Jon Hart [00:39:38] I was just thinking, thank God for grandchildren, because that's, you know, then. Now they'll talk to the doc because they'll talk to their great grandson. Yes. Dr. Faisel Syed [00:39:46] So suddenly, when I have the telehealth visit with my patients, which are my seniors, I have now gotten indoctrinated into the special club. And I see here Chris, Chris has a question here about the lens into the patient's home. This is. Yeah. You know, Chris, I have to tell you, one of the most basic things about doing telehealth, and especially with geriatric care, is just how when the our patient population gets comfortable with the primary care doctor, it's a beautiful relationship, but they'll tell me that the diabetic will tell me they're not drinking soda. And then and then they'll go to shop. Well, let me show you the fridge. And they open the fridge and sure enough, there's like the cans of Coke and Sprite. There's juices and things that shouldn't be in that fridge. And but I would never have been able to see that. I never even thought about being able to see that in a patient's home up until now. Dr. Jon Hart [00:40:39] Yeah, well, because you're not old like Dr. Dan and me, where we actually did house balls and we're physically in the home. And I remember going and seeing patients and. And the granddaughter, the patient would be whipping up big cat head biscuits in the frying pan for me to eat later. But I think I think it's a great point to be made and that is that so much valuable information can come from being in the home and whether even if that's in a video thing, because to your point, you can say, hey, show me what's in the fridge, bring your box of medicines. Let's look at this box of medicine. Show me the floor of your house. I want to see, are there rugs? Are there things that you know or did that little yippy dog that was that was barking in there while you're trying to talk to the patient? Is that a trip risk? You know? So you learn all those things. I think that's a great point that was made. Dr. Faisel Syed [00:41:36] I feel like just efficiency of care in general. If you had doctors focused on doctoring your primary care doctor doing real primary care. You know, I feel for something like we were talking earlier about the knee pain for the orthopedic surgeons who are looking at a knee pain that wasn't properly managed from the primary care doctor because of whatever. You know, many times, oftentimes, it's because they just didn't have the time. I know that they could handle that situation. But when you have specialists doing primary care work but getting reimbursed at the specialty rate, it's a pity. What a shame. What a waste. And so when you have doctors like we had the primary care doctor allow the primary care doctor to practice to their full scope of being a family physician or or an internist to reduce the unnecessary specialty referrals. And then also, America's a young country. The average American is only 37 years old. I just read that they're somewhere like now 150,000 nurse practitioners in America, 200,000 primary care doctors with the technology and now with the nurse practitioners and the physician assistants. And we're talking about if we had a culture of prevention, we've got the teams already in place and the country is a young country. Average Americans, only 37 years old. I just feel like the technology exists. We have the drive. Perhaps people just need to see like places like doctors, like us and this whole risk world just really just scaling out and hey, it's doable. Come learn, try to do it yourself. If not, please come join us. Dr. Jon Hart [00:43:15] Yep. Totally agree. Dr. Faisel Syed [00:43:18] Well, Dr. Hart, thank you so much for a great evening. We went a little bit over. I'm sorry. I want to try to keep it to 30 minutes, but sometimes it just can't, you know? And I appreciate you for coming on tonight. It was a lot of fun with the cameras. One panel, we were both on the carriers, one panel just a couple of weeks ago, and we didn't even make it through halfway through our slot. Dr. Jon Hart [00:43:42] So, yeah, no, I between the two of us, we're we're a couple of grabbers. And so we did a half hour is not near enough times hardly to say hello. So I appreciate being on here and I, I still so appreciative of you pre-reading my book and making a comment that we put on the cover and then just thrilled about that and always would welcome further conversation about value in health care and the patient-physician relationship and everything that goes into that. Dr. Faisel Syed [00:44:19] Absolutely. And Dr. Dan. Thank you again. I hope your Internet didn't go out. There's an iPhone happening in Richmond, Virginia, and I was ready for the Internet to go out. And I must say what a pleasure it is for us to be able to just talk shop, talk about value-based care. We're talking where three doctors in different parts of the country. Dr. Hart and I are pretty close together, but just being able to talk about how we have a model, we have a way where you can restore the doctor-patient relationship, you can restore the doctor-to-doctor relationship and just move away from this nonsense hospital-driven system. So thank you so much. This is really doctor dance. If it wasn't for Dr. Dan, I would not be doing this stuff on social media. Dr. Jon Hart [00:45:10] We appreciate you, Dan. Dr. Dan McCarter [00:45:12] Absolutely. It's great to be here with you. And I. I think just, you know, talking about the doctor-patient relationship and restoring the sanctity of that is just that that's where we all need to get to is doing what's right for the patients. Dr. Jon Hart [00:45:29] Yes, sir. Dr. Faisel Syed [00:45:30] Well, thank you. And to our audience, thank you so much for participating. We love the questions. We love the comments. Thank you so much for joining us this evening. Sorry we went a little bit over trying to try to keep this from eight, eight, 830. But, you know, sometimes you just can't help it. For more information about today's topic and to explore career opportunities with ten men, please visit ten MEDCOM. We're on track to open another 500 centers across the country. That means we need 2000 doctors, bunch of nurses, bunch of staff. We believe access to primary care is a right, not a privilege.