Unveiling Doctors' Struggles: Pioneering a New Era of Empathy and Reform in Medicine with Dr. Scott Ellner

Episode Transcript
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Parker Condit (00:00):
Hey everyone, welcome to Exploring Health
Macro to Micro.
I'm your host, parker Condit.
In the show.
I interview experts from allareas of health, and this can be
in areas you might expect, likeexercise, nutrition and mental
health, while other topics maybe in areas that you're less
familiar with, likeunderstanding how exactly our
healthcare system works and thetoll it takes on our doctors,
and that's something we go overin today's conversation.

(00:22):
My guest is Dr Scott Ellner,who's a general surgeon and
healthcare executive.
Dr Ellner is a doctor ofosteopathic medicine and holds a
master's degree in healthcaremanagement from Harvard
University, among a long list ofcredentials which can be found
in full in the description, andI think this will be an
interesting perspective for alot of people to hear, because
it's easy to rail against thehealthcare system here in the US

(00:44):
, and a lot of times doctorssort of get lumped into that
negative light, probablyunfairly, and I'd say more often
than not they're just asunhappy as their patients being
stuck in a system that is lessthan optimal, to put it lightly.
So today you're going to get aninsider's perspective and hear
what it's like from the doctorside, and we start off with a
very under discusseddiscussedtopic, which is physician

(01:04):
impairment, and that'sunderstanding what happens when
senior and well-respecteddoctors start declining mentally
and it starts putting patientcare at risk.
We later go into reimbursementmodels, which is how money moves
in the system, and if you wantto understand how decisions are
made in the healthcare system,understanding how the money
works is a crucial first step.
And then, finally, we get intosome current events in

(01:26):
healthcare and we talk aboutwhere we see things going in the
future.
So by the end of today'sepisode, I think you'll walk
away with a better understandingof how money flows through the
healthcare system and you'llalso be able to bring more
empathy to the doctor-patientrelationship, now having a
deeper understanding of thephysician side of that
interaction.
So, without further ado, I hopeyou enjoy my conversation with

(01:55):
Dr Scott Ellner.
Dr Scott Ellner thanks so muchfor being here.
Great to be here, yeah.
So today's conversation as kindof consistent listeners are
probably going to understand orare going to have an
understanding of, most of theseare around the patient side or
the consumer side, understandingthe healthcare system and you
know, I think, rightfully so Ibring about a fair amount of

(02:16):
criticism to the healthcaresystem and there are certain
things that you know require tobe called out.
One of the things I don't thinkgets enough attention is
understanding the medical sidefrom the medical doctors,
understanding the empathy andthe compassion that's required
on that side because they'realso operating in a healthcare

(02:36):
system that is obviously notideal.
You have a handful of storiesand anecdotes that we're going
to go through to get a betterunderstanding of that side, and
that's where I think we're goingto go through to get a better
understanding of that side andthat's where I think you're
going to offer a really uniqueperspective.
So I'd love to start justgetting an idea of how you
describe physician impairment,because I think that story is
going to encompass a lot of therelationships that are involved

(03:00):
with the education withinhealthcare and then also
understanding just kind of theframe of the rest of the
conversation.
So I think starting withunderstanding physician
impairment will be a great placefor us to start.

Dr. Scott Ellner (03:12):
Sure, and I appreciate you bringing up this
topic.
It's an important one.
We've seen the issue ofphysician impairment become ever
more so present, actuallybecause of the pandemic, and I
want to just remind thelisteners that physician

(03:34):
impairment doesn't mean youcan't perform your duties well
if you have a chronic diseaselike diabetes, or you have some
sort of physical type ofdisability.
Impairment occurs when youcannot perform your duties in
accordance with the ethicalobligations of the Hippocratic

(03:58):
Oath do no harm.
And the challenges that we'reseeing with healthcare not just

(04:29):
with physicians but also withother healthcare professionals
is that the stress, theadministrative burden, the
challenges with something suchas workplace violence are
actually creating an environmentwhere healthcare professionals
are feeling more stressed outthan ever.
They're suffering from mentalhealth issues, behavioral health
issues, sometimes they resortto illicit drug use, such as
opioids, and becoming addictedto painkillers and alcohol abuse

(04:50):
.
And then there's this loss ofthe idealism of why many of us
went into healthcare, and thatwas to really serve people, to
serve vulnerable populations,care for others, to improve
their health.
And when the stress gets sointense and, by the way, on

(05:15):
average most people doexperience some form of stress
10 times a day, whether it'straffic, whether it's finding a
parking place, whether it'shaving an argument In healthcare
, particularly working in ahospital, it's 10 times an hour.
So the level, the intensity ofthat stress caring for people

(06:02):
and then forgetting to care foryourself leads to impairment and
we've seen this with,unfortunately, with physicians
went into their professions toserve a calling.
But with all the challengesthat we're facing today and

(06:24):
we'll go into more detail aboutthose challenges there are
sometimes issues that arisewhich you know we need to help.
We need to care for ourhealthcare workforce,
essentially, show compassion.

Yeah, exactly, I think that's a great point and
it's just so often.
I've talked to so many doctorsand it is exactly that they
they're just as frustrated thatthey can't practice medicine in
the way that they want to thatbest serves patients.
But again, it's just we'reoperating in the system that
doesn't necessarily facilitatethat as well as they like or at

(06:57):
all.
Can you give an example ofphysician impairment, just to
kind of bring this kind of bringthis concept down to earth for
a lot of people impairment, justto kind of bring this concept
down to earth.

For a lot of people, yeah, this is, and again
I want to stress, you know,physicians can perform with
having disabilities or otherchronic diseases.
Impairment is when youremotional balance, your
well-being, gets to a pointwhere actually there's a risk of

(07:30):
creating harm harm toward thepatient, harm toward the
healthcare professionalthemselves or to the people
around them.
And so let's talk about anxietyand depression.
We saw mental health became animportant issue and continues to

(07:53):
be a very important topic todiscuss in relation to
supporting our healthcareworkforce because of all the
demands put on them.
Supporting our healthcareworkforce because of all the
demands put on them.
When depression starts to setin and I'll be honest, you know,
as a physician myself, I'veexperienced episodes of

(08:14):
depression you start to losethat drive, you start to lose
that ability to stay focused ondoing what's right for the
patient.
You're just trying to surviveand get through the day, and it
may be because you'reoverwhelmed, it may be because
you're having stress at home, itmay be because you're not

(08:38):
feeling fulfilled in the workthat you're doing.
In the work that you're doingand you're actually at risk of
people suffering harm and whatwe talked about a lot,
particularly with situationsthat occurred during the
pandemic, was moral injury,feeling like we just could not

(09:02):
perform to our absolute bestlevel or potential to serve our
patients, and it creates thisperpetual cycle of not feeling
good about yourself, not feelinggood about what you're
accomplishing and then losingyour desire to actually do

(09:23):
what's best for the patient.
Your desire to actually dowhat's best for the patient.
Mental health is one issue.
When you resort to substanceabuse we saw in my experience.
There was a colleague who wasaddicted to opioids.
He was having a nursepractitioner in his office

(09:47):
actually write prescriptions forhim because he had low back
pain which he developed from aweekend outing playing softball
changed.
He became incredibly short withhis staff demeaning, belittling

(10:08):
in some instances and thenactually started having
relationships that wereinappropriate with patients.
Of course you know when it getsto that point people need to
call that out and people need toaddress it because it will not

(10:51):
only perpetuate but it will orother people.
It's unacceptable.
But you have to realize thereare factors that lead to this
happening.

So, generally speaking, I mean, I'm sure this
can happen at any point in yourcareer, but do you find it
happening later in your career,with like cognitive decline and
just sort of a compoundingeffect of this high stress
situation constantly being kindof imparted on the physician?

So that's a good question.
So as we talk about the moresenior physician, as they get
toward the twilight of theircareer, so I want to separate
that out a little bit because Ithink that's important.
We in residency, as a surgicalresident, I was the chief

(11:51):
resident in a very difficultesophageal case on a 21-year-old
young lady who unfortunatelyhad problems with swallowing,
and my attending surgeon at thetime was 84 years old, Well

(12:11):
regarded globally, known for hiswork, and I could see he was
struggling.
He was struggling.
It was a difficult case and itwas hard for me to watch and I
also knew we had a young lady onthe table here and every stitch

(12:35):
that you place, every suture torepair that esophagus and this
was a redo case, so it wasn'tlike it was, you know, new
tissue.
This was a difficult casebecause he was renowned for his
work in this area.
You had to be precise and Iknew he was struggling and it

(12:56):
wasn't because you know ofanything more than just at that
point.
Your ability, your dexterity,your even your judgment isn't
what it was in your 30s, 40s.
So I made a very, very toughdecision to ask the nurse

(13:21):
quietly to call one of my otherattending surgeons to come in to
help.
That's difficult to do.
That's difficult when you knowsomebody who is incredibly
well-respected within theirfield and has done great things,
has published hundreds ofarticles, and then you have to

(13:45):
surreptitiously go around andask someone to step in for them.
It's like an athlete.
It happens in pro sports Samething.
They're just not on their game.
They're not in the flow statelike they used to be.

Yeah, but it's hard to, as a rookie, tell the
superstar athlete on the teamthat you know they're not,
they're not the one carrying theteam anymore or anything like
that.
Even even a coach can be in atough position there.
To bring it to the sportsanalogy, so that that's a case
where you described, uh, whereaction was taken, and to be a

(14:22):
resident, um, and to be able todo that I'm sure it takes a lot
of courage.
Can you describe therelationship between residents
and attendings, because thatdynamic can lead to what I want
to get into next, which is goingto be a situation where nobody
says anything, which probablyhappens quite often.
But I think if you can startwith describing sort of the

(14:44):
power dynamic within the medicaleducation system, I think
that'd help frame the rest ofthe conversation.

Yeah, at least when I went through medical
school and residency, which wasthe late 90s 2000s, it was
before there were work hourrestrictions, fully work hour
restrictions, which I think now,looking back, is a pretty good
thing in some ways and maybe notso great in other ways.

(15:15):
But the most important aspectof training in different medical
specialties is this authoritygradient.
As a medical student, you areessentially on the low end of

(15:35):
the totem pole and you're thereto learn, you're there to listen
and the ability to speak up.
It can be scary because youdon't want to look bad.
You're also being graded onyour performance and sometimes
you're being asked a lot ofquestions.
The term we use is pimping,which is you get pimped on

(15:59):
questions and it's weird, butyeah, that's what they use as a
term as a resident, as an intern.
An intern is a first yearresident.
Again, you go right back to thebottom and then, as you ascend

(16:19):
throughout your residency andeventually become a chief
resident, you still have todefer to your attending.
Now the attendings also havetheir hierarchy where you have
junior attendings and you havemore senior, and then you have
the luminaries, you know, whoare well regarded in different

(16:41):
societies and who have publishedand there's a term I want to
use that I think is reallyimportant, that that needs to be
emphasized, and it's calledpsychological safety.
I want to make sure I'm correcthere.
I believe it may have come fromAmy Edmondson out of Harvard,

(17:05):
who really studied behavioraround how people interact in
group settings when there is aneed to speak up, and many times
there are situations wheresomebody is about to maybe

(17:27):
operate on the wrong body partand nobody speaks up because
there's a fear of actuallyspeaking up.
Can you imagine that happeningon an airplane?
Can you imagine that happeningin any other industry?

Are you familiar with the checklist manifesto by
Atul Gawande?

I very much am yes Okay.

Yeah, so I think it's examples in that book that
they ended up taking in themedical field A lot of the
protocols from the aviationfield for that exact reason,
like I think now it's like youyou mark appendages with a
Sharpie prior to surgery to toavoid things like this.

Well, and actually Atul Gawande was
somebody that I highly respectand did a lot of my research
after using the surgical safetychecklist in the operating room,
because I think that checklistsaves lives, and the whole
approach of going through apre-briefing and talking about
the case beforehand and thendoing what's called a timeout

(18:41):
before you do anything on apatient to ensure that you're
doing something in the rightlocation is incredibly important
.
And then afterward you talkabout it what went right, what
could we have done better andthen afterward you talk about it

(19:15):
what went right.

What could we have done better?
But it's important to have thecomfort where anyone in that
room, regardless of their statuson that authority grading, can
speak up, particularly if theysee something that's not right.
So it's a tough dynamic.
Right Because obviously themedical field has evolved so
well, because knowledge has beenpassed down in a very
deliberate way, and one of thoseways is through this sort of
gradient of the more seniorleaders within an organization
passing that information down inthis particular way.

(19:38):
But at the same time, how do youmaintain that authority and
that structure for the educationand sort of the order of the
operation but still have peoplefeeling safe enough to speak up
in these situations when youknow it's very easy to be in
that room, especially with avery esteemed senior leader, and

(19:59):
you see them doing somethingwrong, but you're like
everything else in your mind islike, it's like the halo effect,
right, where you're like theycan't possibly be doing
something wrong.
Right, they know so much, theyknow so well I must be mistaken
on which leg we're supposed tobe operating on.
So it's a very tricky problem.
Have you seen progress in, Iguess, since then?

(20:21):
Because you've worked as ahealthcare executive so you've
kind of seen different sides ofthis and how administering
policy can help improve.
Have you seen improvements inthis case, since you were a
resident?

Yeah, it's a great question.
Absolutely, and I think so justto let the listeners know it's
much safer today to go into thehospital and have your
interaction with your physician,whatever it is because of
people like Atul Gawande andothers who have promoted what's

(20:55):
called high reliabilityprinciples or high reliability
organizing principles, and thesewere tools that were adapted
from the aviation industry, thenuclear power industry in order
to ensure that in high-riskenvironments like healthcare, we

(21:18):
implement programs where, ifyou see something, the approach
we teach people.
In my last few health systemsthat I ran, we taught people how
do you speak up.
The best way to do that is toask a question or say I have a

(21:39):
concern, and it's a way thatdoesn't escalate to the point of
creating tension.
It's a way of escalating to thepoint of creating inquiry and
allowing people to have aconversation.
So, looking back today with theolder surgeon that I was in

(22:06):
that case around the esophagus,I probably would have said,
instead of behind the scenesasking the nurse to call my
attending, I probably would havesaid to the senior surgeon Dr
So-and-so, I have a question.
Is there something that I cando to help you?

(22:27):
Is there something we can do toaddress this situation I'm
seeing a lot of blood, a lot ofblood and do it in a
non-threatening way thatmaintains dignity, respect and
the authority.

It's almost like searching for clarity versus
conflict.

Absolutely, and I think that's where we get
into trouble many times is,instead of approaching that in
an effort to define clarity, wecreate conflict and then that
creates tension and that leadsto sometimes bad behavior.

So going again.
I want to go back to thesituation where something
doesn't get said and there theredoesn't, it being like a very
adverse event for anyone who'sin medical school or residency.
Is there adequate training?
Maybe you can speak to when youwent through it and maybe where
we are now for dealing withlike the emotional toll of

(23:32):
possibly losing a patient in asituation where it wasn't it was
just a tough case, it was moreof a case of I didn't say
something when I could have, um,because, yeah, having all the
school, uh, the tools and theskills required for whatever
specialty you're going into as amedical doctor obviously
required, but this seems likeone of those things that happens

(23:54):
and probably I mean I've justseen like the lack of nutrition
training going through medicalschool.
So is there adequate skilltraining around emotional
resiliency and emotional toolsto deal with loss as a medical
doctor?

You know, parker, that's such a great
question how do we teach theyounger generation of healthcare
professionals physicians,nurses, those who are going into
the allied health professionsto deal with loss and to develop
resilience or hardiness?
I would say there's so muchinformation that we're trying to

(24:37):
learn today, and then, on topof that, add how to document
appropriately in the electronichealth record, which has only
added more of an administrativeburden.
I think the skills to teachpeople how to be resilient

(24:59):
during tough times is sort ofoverlooked.
There are some organizationsand training programs and
schools who are now thinkingabout emphasizing I don't want
to call them soft skills,because they're they're not.

(25:20):
These are important skills thatthat uh are that's fine.

That's a term that people can latch on to.

Right, but the but, the reality is um.
First time you see someone dieand they're under your care.
It's heartbreaking.
And I remember, I vividlyremember, a patient, a
47-year-old man, who I wascaring for.

(25:49):
He was actually seeing mebecause he was interested in
weight loss surgery, but he washaving pain in his right side
and we did a CT scan after a fewweeks and it turns out he had a
metastatic colon cancer.
So colon cancer had spread tohis liver and he died not even

(26:13):
six months later.
And I remember talking to hiswife and his 12 year old
daughter just before he waspassing, explaining to them that
there was really nothing morewe could do.
It takes a toll on theclinician and you know it's okay

(26:35):
to cry, it's okay to to showemotion, it's okay to be
sensitive in those instancesbecause you care and, uh, we, we
don't have to always bedesensitized, because I think
what that does is it hardens usto the point where we become
cynical.

We lose our our purpose or sense of purpose at
times have you found thatthere's ever environments that
don't necessarily facilitate the, the compassion and the ability
to feel your emotions, and thenpeople do end up getting
desensitized and cynical andthen you end up seeing people
exit the industry.

(27:12):
I'm thinking more examples innursing than physicians, more so
around like the pandemic andalso issues around like safe
staffing ratios.
The example that kind of comesto mind is not in directly,
where there's somebody underyour care but a nurse couldn't

(27:33):
do everything that he or shewould have wanted to because the
staffing ratio wasn't adequatein a particular facility.

So are there issues like that as well?
Of the epidemic is the abilityto create the appropriate levels
of staffing so people aren't sooverwhelmed that they feel like
they're not doing their best.
And even before the pandemic Ithink that was starting to

(28:11):
happen.
And what the health systems arefacing today is workforce
dislocation.
We're losing really strongnurses who love what they do,
but the financial dynamics don'tmake it easy to continue to

(28:37):
support the labor force, becauseit is the number one cost for
health systems is labor, and tostrike that balance and have the
right ratio so that peopledon't feel overwhelmed and are
working to their highestpotential.
It's difficult to navigate thatfine line and I think that we

(28:59):
saw the requirement of bringingin a lot of outside contracted
labor into the workforce becausea lot of people left.
Some of them are coming back,but still it's incredibly
difficult to recruit people intothe healthcare profession
because they know how difficultit is.

So we're now parlaying into the financial
side of things, which I think isrequired for people to
understand the dynamics of thehealthcare system.
So physician burnout orhealthcare professional burnout,
physician impairment, do youthink any of that's related to I
mean, it has to be related tothe financial model that we're
operating in.
I think it'd just be easiest ifyou first describe the

(29:46):
predominant payment model of feefor service within the
healthcare system and then wecan kind of talk about how that
influences decisions, kind of upand down the board.

Talk about how that influences decisions up
and down the board.
Yeah, so to make this, just tryto a service whether it was a

(30:17):
primary care visit, whether itwas performing an operation, you
got paid.
You got paid a certain amount.
That's called fee for service.
So you provided a service andthen you were reimbursed.
Reimbursed is not the correctterm either, because reimbursed
means that if you take everybodyout to lunch and it's on the

(30:41):
company, the company willreimburse you for the full
amount.
That doesn't happen.
Instead you get a payment whichcould be maybe 60% of what you
charged.
So again, there's some nuancesthere.
So fee for service is youcharge a fee and you get paid a

(31:02):
certain amount from a thirdparty.
Typically it doesn't comedirectly from the patient.
Now the patients do have to nowpay co-pays.
They have a deductible, have tonow pay co-pays.
They have a deductible, whichis incredibly expensive now.

(31:24):
But the reason whyfee-for-service and the
mechanism of how healthcare hasevolved into this payment
structure really stems from theearly part of the 20th century,
back in the early 1900s, withthe development of insurance,
employer-sponsored insuranceprograms.
So essentially the medical carethat people were receiving over

(31:47):
time was other people's money,and so today we're trying to
combat healthcare expendituresand the costs.
By 2030, the healthcareexpenditures will be over $7
trillion 20% of the US GDP.

(32:07):
Despite challenges in thoserising costs and trying to
provide value in healthcare, wecontinue to outspend other
countries.
So the fee-for-service modelwhile I think it can work, what

(32:33):
it does lead to also issometimes something called
unnecessary medical services.

So doing things that quite aren't really
necessary.
I think there's nuance there aswell, because a lot of it can
be done defensively, because wealso live in a very litigious
country where there can beprocedures done because there's
a potential risk a few yearsdown the line that you as a
physician is going to be on thehook for missing something on a
CT scan, right when somebodycomes in with what you think is

(33:08):
dehydration and you you miss ananeurysm or something like that.
Um is also on the financialside.
There is a responsibility onthe population of loving to take
people to court and takingdoctors to court.
So there's that side of it aswell.
So that's fee for service.
There's a shift towardssomething called value-based

(33:31):
care or value.
Can you describe that, andmaybe I'd love to actually just
hear your thoughts on value andwhat do you think that's a
viable solution, kind of movingforward?

Right.
So value-based care really cameout of work that was done
through the Affordable Care Actand, by the way, the Affordable
Care Act wasn't really aboutaffordability, it was about
improving access.
So value-based care is now youget paid for the value you

(34:07):
provide to the patient and thevalue equation is the outcome
divided by the cost.
So if you have high quality, agreat outcome and low cost, that
increases value.
And so the payment models.

(34:28):
Now today and we'll talk alittle bit about Medicare,
because I think that's importantto discuss Medicare is moving
from a traditional approach,where it's fee-for-service, to
now Medicare Advantage, which isa value-based product that is
run by commercial health plans.

(34:49):
That incentivizes physicians toprovide value.
So the physicians are paidbased on their performance, on
managing chronic diseases orkeeping people healthy, keeping
people actually out of thehospital and potentially

(35:12):
performing less and thus bylowering costs.
So Medicare fee for service orthe traditional Medicare, which
was passed in 1965 in the SocialSecurity Act was you do
something, you get paid for it.
Medicare Advantage, orvalue-based care, is today we do

(35:34):
things that will bring value,hopefully will bring value at a
lower cost and will provide highquality.

So it sounds like on the surface.
When I first started learningabout this, value-based care
seems like a great proposition.
I also really enjoyed the ideaof Medicare Advantage.
It also seemed like a greatproposition.
I have concerns about Medicarebeing shifted towards private
companies or in the form ofMedicare Advantage and the

(36:05):
control kind of going away fromthe government to these private
entities for our agingpopulation.
I also have concerns about thefinancial incentives in that
model as well.
I guess at a very surface level, fee for service encourages
more procedures, more things tobe done, because that's where

(36:26):
the revenue is tied.
On the other side, value-basedcare sort of incentivizes less
things to be done and you cankind of keep more money, as long
as they don't end up having areally adverse event like ending
up in the hospital.
So maybe if you can just speakto a little bit more depth about
the good and the bad ofvalue-based care, Well, I think

(36:51):
you described it pretty well.

So, as we transition, or try to transition
, into value-based care delivery, the idea is to minimize the
amount of care services medicalcare services, expensive care
services in order to keeppopulations of people healthy.

(37:18):
The challenge is that whenyou're dealing with populations,
there are always going to be afew outliers.
And so, for example, let's sayyou have a managed care plan
that is responsible for MedicareAdvantage and they have an

(37:39):
algorithm that says, if a womanunder the age of 65 has an
abnormal pap smear, has anabnormal pap smear, instead of

(38:01):
referring them to an OBGYN forpotential workup in a biopsy,
they have to have four abnormalpap smears, which is a lot
cheaper than a biopsy, beforethey can get a referral to a
specialist.
The problem is you're going tomiss some aggressive cancers.

Sure Sure.

Now it's a numbers game if you think about
it right.
So one person may not benefitfrom being part of this
value-based delivery system, butas a whole, it does, in an
effort, decrease costs and keeppeople relatively healthy
relatively healthy.

(38:42):
So the downside is that somepeople are going to miss being
diagnosed or have a delay indiagnosis, misdiagnosis or delay
in diagnosis, and then thatgets into the legal
ramifications that you talkedabout and the duty of care and
breaching that duty.

What about from I'm not sure how to phrase this
the Medicare population 65 andolder?
Obviously it's a big populationright now and the shift has
been drastic from Medicare toMedicare Advantage over the past
decade and it's continuing toramp up.

(39:24):
It's 50% of Medicare patientsor Medicare beneficiaries are on
Medicare Advantage.
Now Is there a danger of thecontinued shift towards Medicare
Advantage?
I don't necessarily know thatthere is because I don't
understand macroeconomics thatwell.
I do have concerns about maybesome of the big players right,

(39:47):
because it's not evenlydistributed, this Medicare
Advantage population either.
It's like United has a hugestranglehold on that industry
and they're already a monster ofa company.
I just don't know if it's greatfor one company to have so much
control over what is ourbiggest industry in this country
, as you described, going to be$7 trillion, t trillion with the

(40:09):
T by 2030.
And for reference, like when alot of people are saying, oh, I
wish we had more money forinsert your favorite thing in
this country, they usually say,oh, if we spent less money on
defense, we could do this otherthing, but we spend less money
on defense.
We could do this other thing,but we spend way more on
healthcare than we do on defense.
So just I want to call that outfor people who maybe don't

(40:30):
appreciate how much money wespend on healthcare here.

Well, the insurance companies are doing
well, I will say.
However, however, theDepartment of Justice is

(41:03):
scrutinizing the big insurers,commercial insurers like
UnitedHealthcare.
Unitedhealthcare orUnitedHealth Group is having a
bit of a Boeing moment.
A Boeing moment, right.
So Boeing, as you know, ishaving its struggles.
We talked about the airlineindustry.
Well, you know, a door flyingoff mid-flight from your
airplane is not a good thing.
Unitedhealthcare has been in thenews recently because of a
cybersecurity attack on theirchange healthcare division,

(41:27):
which they purchased for acouple billion, I think and are
using it for adjudicating claims, which means paying out claims
to their providers who are underUnitedHealthcare contracts.
It's not a good look, becauseUnitedHealthcare is really

(41:51):
struggling for getting thoseclaims out because of this
breakdown.
Department of Justice is alsolooking at UnitedHealthcare
Division of OptumCare forantitrust because I believe it's
now roughly one in 10physicians is now an employee of
OptumCare.

(42:12):
So you're creating what'sallegedly an anti-competitive
environment where it could besaid there might be attempted
alleged, attemptedmonopolization of the industry.
And then one other case thatUnitedHealthcare is facing goes

(42:38):
back to what we were justdiscussing with Medicare
Advantage.
So the idea with MedicareAdvantage is the sicker the
patients are based on a riskseverity coding system, the more
the plans will get reimbursedby the government.

(42:58):
So if somebody has diabetes,with chronic renal failure or so
their kidneys are failing fromtheir diabetes, and you put that
, you document that into yourelectronic health record, you
will get paid more.
Next, the following year,including UnitedHealthcare.

(43:20):
What UnitedHealthcare did isthey scrutinized millions of
claims using an artificialintelligence model, machine
learning, looking at if theywere coded appropriately, and
then those that were undercoded,they upcoded them.

(43:43):
What they didn't do is look atthe codes that were overcoded or
upcoded and bring them down towhat they should have been.
So the Department of Justice isnow looking at that case for an

(44:04):
alleged false claims actviolation.
So again, the insurers arereally positioning themselves to
.
I would say the insurers arepositioning themselves to really
have a stranglehold over thehealthcare industry.

I think that's a great example of.
I think there is absolutelynefarious activity sometimes
when there's this much moneyinvolved.
It's a great industry to makemoney but like what you
described makes sense, if apatient is sicker based on more
conditions, severity ofconditions through what's known

(44:47):
as a RAF score, it's going totake a little bit more resources
to keep them healthy in a givenyear.
So they should the plan shouldbe compensated higher for taking
on the risk of that particularpatient.
If you take on a whole bunch ofthose riskier patients, you
should get paid more.
The problem is it's like firstorder thinking right.

(45:07):
It's kind of like chess movesback and forth, so the
compensation is available in anappropriate way and then the
other side goes.
Well, how can we take advantageof this?
Maybe just a little bit more?
So I think things are neverreally done in a really
nefarious manner.
It's just there's an incentiveand then you get a bunch of

(45:29):
really smart people becausethere's trillions of dollars at
stake to go.
How can we get more of that?
And then there needs to be moreregulation to close up some of
the loopholes that were foundover here, and you just keep
going back and forth, which Ithink, is how we ended up with
this wildly complicated kind ofbig, cumbersome boat of an

(45:51):
industry that does notnecessarily want to turn very
quickly.
Nothing seems to happen veryfast in this industry.
But I'm just curious so youmentioned this earlier that we
as a nation spend more perperson than most other countries
I think any other country andit's, if you compare us to most

(46:14):
other like economic peers.
It's close to double per person.
With that much money, with thatmuch money just in a vacuum,
could you come up with a bettersystem than what we have Not
understand?
Is it possible from a politicalstandpoint?

With the amount of money we throw at this
, we should have better health,right?
Well, I love what you saidbetter health not necessarily
better health care and I thinkit starts way upstream, starts
early in our childhood ofcreating healthy behaviors.
My background is actually inpublic health and I believe that

(47:04):
if I didn't have to everoperate again on someone because
they cared for themselves byeating right, moderating what
they eat, avoiding harmfulsubstances, getting enough sleep
, good sleep, creating socialconnections, minimizing risky

(47:27):
illicit behavior, I think thatwould be the ideal health
industry.

Yeah, so that's actually how you and I first
connected.
I saw you speak at a conferencein July of last year and you
were speaking largely on theselifestyle factors.
Right, it wasn't.
It wasn't, uh, improving RAFscores.
It wasn't.
We're at a healthcare, what isit?
Hmfa?
It was like a re.
It was basically a bunch ofpeople trying to figure out how

(47:55):
to get reimbursed faster or morecompletely.
Um, and you were.
You were there talking about,like, lifestyle factors.
I was like, okay, this is a.
This is the most interestingtalk I've seen at this
conference.
So, speaking of lifestylefactors, I'm not sure how to
influence change in this space,right, because everything just

(48:16):
rattled off.
None of it's going to be asurprise to people Eating
healthy, making sure you getenough sleep, managing your
stress, have strong socialconnections and relationships.
Um, exercise, move your body,get sunlight.
How do we start influencingthis at scale?
Um, and I'm happy to just startin a very theoretical way and

(48:37):
then we can kind of try tonarrow down to how to actually
implement that.
But you have a background inpublic health.
We've been trying to crack thisfor a while.
Right, a lot of people aretrying to figure this out.
It's hard.
We have such a big country, 330million people it's hard to
figure out solutions that workfor everyone 330 million people,

(48:58):
67% are overweight or obese.

Significant amount of the population is also
pre-diabetic or diabetic.
Yeah, I wish I had the magicanswer.
I wish I had the Ozempic forbehavior change.
You know people want a quickfix and unfortunately it starts
with, um, really your mindsetand the will, not just wanting

(49:33):
to change, but the willingnessand the understanding of how to
change change behavior.
Um, you know, I, I loved, Iloved operating on people
because it was a quick fix.
But I also recognized that alot of what I was operating for,
whether it was injury orillness, could have been totally

(49:55):
preventable or avoided by earlyrecognition of disease and
behavioral change.
You know, maybe it's throughgamification and incentivizing

(50:15):
people in a way that will createsome sort of external
motivation for them to changetheir behavior.
Maybe we can get to peoplethrough their own intrinsic
motivators.
Maybe it's creating moreempathy and compassion.
Or maybe we just are terribleat providing access to the right

(50:40):
, healthy choices and peopleneed support navigating a
complex system.

I'm sure it's some of all of that.
The point you mentioned earlierwhich was psychological safety
within a medical setting that'ssomething I want to kind of
circle back to.
I'm 35.
Setting that's something I wantto kind of circle back to.
I'm 35.
Even just in my lifetime I'veseen the sense of community and

(51:12):
the strength of relationshipssort of diminish.
I don't know if it's with theability to travel and move is
just a lot easier, or it'stechnology, or it's a
combination of all these thingswhere you can stay connected for
anyone listening I'm airquoting, connected um, through
technology and you can sort ofyou can sort of outsource a lot

(51:35):
of, a lot of part, many parts ofconnection where you would have
to normally spend time withsomebody, have a real
conversation with somebody, goover to their house.
Now you can post something onInstagram and get a few comments
and likes and that will get asimilar feeling of connection.
But it's very short, it's notlong lasting and it doesn't

(52:00):
necessarily contribute tosomething positive.
I don't think in the long run.
But I'm curious if you thinklike, do you think the sense of
community is also diminished?
And I don't know, I feel likewe're life is sort of cyclical
right, so I'm hoping that we'regoing to get to a shift back.
I feel like we've shifted awayfrom community and I'm curious

(52:21):
if you think we're going toshift back towards more
community, almost out ofnecessity, like I don't know if
we can get any more isolatedfrom each other.
At least I hope not.

It's a bit of an oxymoron, right, or, or a
paradox.
We can be global, we can havecolleagues who are global, that
we communicate with every day,but are we really connected?
Are we really creating thosedeep connections that impact how

(53:34):
we feel toward one another?
In fact, I've talked a lotabout this.
What you're bringing up, thissafety and feeling appreciated,
wanted.
I think we need to spend moretime showing gratitude,

(53:55):
recognizing people for what theydo and being open to diversity
of thought, diversity of purpose.
Things are very polarizing todayand I think that's what you're

(54:16):
alluding to is.
It's creating these dynamicswhere there's a loss of civility
and let's.
I mean, I don't want to bringthe politics into it, but we saw
this in healthcare, where theviolence against healthcare
workers was staggering and therewas a loss of trust toward

(54:41):
physicians particularly, andeven today I think it still
continues and I think physiciansalso.
We have a part in this, becausewe have to remember that the
way we were trained was apaternalistic approach.
I say what you need, I say whatyou should do, so why aren't

(55:02):
you doing it?
Why aren't you adhering to theregimen?
And maybe there's a differentapproach on how we get people to
buy into healthy behavior.

Yeah, yeah, it seems like the younger and
younger generations I don't evenwant to say want, but need
things to be more collaborative.
The, the, the paternal approachas you described it is, I think

(55:33):
, being readily rejected by sortof the generation behind me,
and they're they're much more inthe, the collaborative camp.
I also want to circle back tothe point you made about access.
I always go back and forth tothis right, because I have spent
a fair amount of time on socialmedia and especially in the
health space.
I kind of go back and forth.

(55:54):
I'm like is it worth putting avideo up just informing people
that eating lots of fruits andvegetables is important?
And like that's important partof your diet.
I'm like it's so simple.
And then I ended up do I?
I post something about that, anda lot of the comments are
coming like oh, why, why do weeven need to say this?
Doesn't everyone know it?
Um, but I think there is stillthat piece of education.

(56:18):
There's a study that came outlooking at the snap program,
where they looked at just uh,snap program, which is like food
stamps or snap plus education.
Um, so people are on foodstamps but also some very basic
nutrition education and theresults on the snap plus
education was like 66 betteroutcomes.
So it's like clearly this, thisbasic education, is still a

(56:41):
requirement.
Um, so it it's hard to knowwhere to even begin.

I love that you brought this up, because I'm
guilty of being one of thosepeople.
So I'm 54 years old, I grew upsurfing, I was really mobile, I
could surf big waves and then, acouple of years ago probably
right around when I turned 50, Iwas in Hawaii teaching my

(57:10):
10-year-old daughter how to surf, and I couldn't jump up on the
board like I used to.
I'm like, wait a minute, whathappened?
My mobility completely changedmy flexibility.
My hips felt like they werestuck in the mud Over the last

(57:31):
couple of years.
I look at YouTube shorts andthere are some incredible
YouTube shorts that demonstratehip mobility exercises that I
just picked up from some randomwoman who is knowledgeable in
physical therapy or in trainingathletes and I do it.

(57:55):
So you know a guy like me who'sa Gen Xer actually.
Um, it appeals to me to watchsomething for about 10 seconds
and then learn how to do a newhip mobility exercise.
And and, by the way, yeah, Ican get back on my board and
surf again because of theseYouTube shorts.

So I I've categorized things into access,
education and then action, wheresome people, some people don't
have access to like they, theyknow what they need to do and
they might even have thefinancial resources to do it,
but they don't have.
Like, there's lots of ways youcan parse out access.
Um, some people have access andthe willingness but they don't.

(58:45):
They just don't know what theyshould be doing.
And then some people know whatthey should be doing, they have
access, but they're they don'thave the drive, the intrinsic or
external motivation to take theaction they want to do.
So, I guess, from like a socialdeterminants of health
standpoint, there's, there'sright, there's, there's no
shortage of work that needs tobe done in this space.

(59:06):
Anytime somebody isknowledgeable in this space, I'm
always curious to ask aboutsocial determinants of health
and you've also operated inhealthcare much longer than I
have have you seen progress insocial determinant, I guess,
like programs or initiatives,and where do you see our big

(59:27):
opportunities that we still needto kind of make strides towards
for make more progress there?

The first time I heard social and behavioral
determinants of disease was in2013.
I was getting my master's atHarvard School of Public Health

(01:00:05):
about social activities thatwould help promote health and
prevent disease, like housingand food deserts.
So that was about 10 years agothe first time I heard it, and
I've seen progress.
I think there's legislationthat's been passed requiring the
insurers to incorporate healthand equity metrics to ensure

(01:00:28):
that people of underservedcommunities are getting access
to care, but I still thinkthere's a long way to go.
There's a tremendously, andI'll tell you where we're going
to face.
The largest challenge right nowis with generative AI and the
algorithmic bias in machinelearning, not picking up the

(01:00:52):
disparities in different racial,ethnic, religious and other
sexual orientation and genderidentity.
That's going to be a problemwhich has to be addressed.
So I guess a long-winded answerto address your question is we
made some progress.

(01:01:12):
I think there's attempts atbeing better, but again, it
doesn't bring in the revenueinto the healthcare industrial
complex like a new drug does ora procedure from a device.

Parker Condit (01:01:31):
Yeah, that's where it's hard, right we all
know the answer, we all know theanswer, but is there enough
money in place to get enoughpeople on that side?

Dr. Scott Ellner (01:01:48):
And currently, the answer is no.
I have a couple of colleaguesthat work for venture capital
firms and they don't want tohear it from me.
If I'm talking about wellnessor, uh, health, don't bother me
with that.
If you're talking aboutspecialty care, we'll listen.

Yeah I was just out in uh, tampa, florida, for
like a one day.
It's like a one day conference,not even a conference, there's
like a private invite thing, butthey just get together and it's
like 50 of us just talkingabout one particular topic.
And the topic this year wasprivate equity in healthcare.
And it was fun.
You know, in a group that smallyou can have really animated

(01:02:34):
conversation to say, and thereare people there from the
private equity side, there arepeople there from the healthcare
side side, there are peoplethere from the healthcare side.
And through eight, nine hoursof conversation you kind of get
to the end of the day andsomebody asked the question like
, does any of this help patients?
And everyone's like, oh no,absolutely not.
Just understanding the model ofhow physician practices get
rolled up, how they privateequity is always going to need

(01:02:56):
to make a return.
You know they're not looking tohold on to those group of
practices forever.
They're looking to have an exitevent and then whoever they
sell to, they need to make areturn at some point.
It's like somebody is going tobe left holding the bag, but we
as an industry just seem to beokay to continue down this route
until I don't know it fallsapart and we just have a bunch

(01:03:18):
of independent physicians againroute until I don't know it
falls apart and we just have abunch of independent physicians
again.

78% of the physician workforce is employed
by either a health system or ahospital, by private equity or a
payer.
In Oregon, actually, there is alegislation that is um going

(01:03:43):
through there, Um, I think it'snow in their Senate to ban
private equity from purchasingphysician practices.

I did see that.
Yep, I brought up.
I brought up that story becauseyou'd mentioned how bringing up
like wellness in those circlesuh, just is not well accepted.
And it was funny because oneguy there brought up the fact.
He brought up kind of what wetalked about earlier.
Like the younger generations,they're like they're looking to
homestead and they don't trustthe medical system, and this guy
got like three sentences intowhat he was saying before
somebody cut them off.
They're like don't talk, don'tyou bring your health and

(01:04:19):
wellness stuff in here?
Um, but it's, yeah, that's justhow that that side of the
industry treats um, treats itCause it's just, uh, it's just a
commodity, right, patients aretheir units to drive revenue, um
, unfortunately, but that'sthat's the reality of private
equity, um, do you have any?

(01:04:41):
I don't want to end on such amorbid note.
Uh, do you have anyencouragement towards like other
models?
Like I'm?
I'm a big fan of direct primarycare, um, cause they are
largely independent.
There's some bigger groups,like marathon health, and I
think they're doing interestingstuff in the employer sponsored
space.
Um, but if you have anythoughts on direct primary care

(01:05:02):
or any other models that you seeas encouraging, I'd love to
hear that.

Yeah, well, I'd like to put a shout out to
the American college oflifestyle medicine, because I
think it's a it's an importantsociety that is now creating a
certification and actually afellowship for physicians to
encourage patients throughlifestyle change or behavior

(01:05:28):
change, and I believe that thosemodels will be sustainable.
I believe patients willappreciate those models much
more.
I believe the employers sodirect-to-employer will
appreciate those models becauseit'll lower their costs if

(01:05:49):
they're self-funded with theirinsurance plans.
I think they can work.
An interesting model that I'mworking on right now and I won't
get too deep in this becauseit's probably for another day is
I'm working with a companythat's creating digital twins of

(01:06:14):
a physician and health coaches.

That's interesting.

Talk about access.
Talk about access.
So patients will have 24-houraccess, daily access, to the
physician's digital twin foranything that relates to their
personal or medical healthhistory, health history and it

(01:06:43):
will occur through a virtualmarketplace, through a portal
that's HIPAA protected, so allthe protected health information
that you worry about will beprotected and to even take it

(01:07:04):
one step further.

There is a whole new digital currency.

that will come out of this, that I'm sure of.
So those innovative approachesare coming.

So I think, with generative AI and sort of these
digital twins that you'redescribing, there's a lot of
things through technology thatare going to help augment the
workforce.
But are we, are we going to bein a really bad place from a
nurse, physician, basically justhealthcare professional

(01:07:36):
standpoint?
Um, because, like, the problemwith these jobs is, like you,
you can't, you can't spin themup really quick.
Um, like, it takes a lot oftraining and a lot of money to
kind of get that training.
Are we going to be okay from aworkforce standpoint?

Oh no, we're.
We're facing.
We're facing a major shortageof physicians and nurses.
Uh, you know and I don't havethat numbers offhand, but you
can certainly look them upthrough the double amc based on
the number of exits and then thelack of interest to school.

(01:08:14):
Unless it's funded somehow,yeah, we're going to have to
rely on other sources ofdelivering help.

I would like to see a future where it's all much
more collaborative, because Ithink, to be fair to physicians
especially, it's been a veryunfair expectation of somebody
to live their life, usuallyuntil they're like 40, 45, and
then they start getting thingsthat happen with their health
and then they go, all right, fixme right.

(01:08:56):
Like that's not a fairexpectation.
Um, but there's lots of otherlike allied health professionals
, right, I think there needs tobe better coordination.
What kind of dog do you have?

Oh sorry.

Yeah.

I've got an Australian shepherd.
That's fine.

I've got two dogs here, so one of mine was
barking earlier.
That's no problem.
I think in an ideal future,something that's like also
realistic is go to a medicaldoctor, or maybe not even
medical doctor, but there needsto be someone quarterbacking
care whether it's a health coach, something like that and then
just much better coordinationamongst other people, where you

(01:09:33):
had a personal trainer,registered dietitian,
nutritionist, health coaches,and then your nurses and and
then your sort of specialists asneeded.
I think a lot of it's beenlumped into the medical world to
this point inappropriately andI think it needs to be more
evenly distributed.
But again, it's a money problem.

(01:09:54):
So I don't know where the moneyand the resources come for all
of that, and I think technologycan help augment some of that,
but usually not at a one-on-onelevel, usually at a, at more a
group level.
I don't know.
Those are just my thoughts onit, but that's just generally
where I'm thinking I was alsotrying to add up something more
positive.

No, you're raising.
You're raising a reallyimportant uh, important point
here about the direction we needto go for value-based care.
It's around creating a team andas a physician, you can't
possibly know all that needs tobe done to care for someone
bring their nutrition habits,their sleep habits, managing all

(01:10:40):
the different chronic diseases.
So if you have a team of healthcoaches, diabetes educators,
personal trainers, that's theideal situation.
So the collaborative approachthat you're talking about and
hopefully, as the newgenerations of people are
seeking out health, willappreciate that type of approach
that's the direction we need togo.

And I think starting people earlier right,
because of all the differenttypes of providers you and I
just listed, there's manydifferent tracks of education
that can be fed to the patient,and a more educated person is
going to be able to make betterdecisions on their own, which
sort of transfers a lot of theagency and the autonomy back to
the individual Cause I thinkwithin health it seems like just

(01:11:24):
kind of as a personal trainerthen working in this industry um
, a lot of people don't feellike an active participant in
their own health.
It's sort of like it happens tothem and they're not really in
control.
So I think finding ways toshift that back to the
individual will be veryimportant and also very

(01:11:45):
empowering too.

Absolutely.
You, as a patient, need to beyour best advocate and to learn
as much as you can about yourhealth.

Do you have any closing thoughts that you want
to add, or that might be a niceplace to wrap up right there?

Sure.
Well, I'll just say that forthose who are interested in
going into the healthcareprofession, there's going to be
tremendous opportunity.
It's changing, it's going to bedynamic and I'm excited about
the future.
For those who are navigatingthe healthcare system and maybe

(01:12:29):
have felt frustrated or wantmore out of their experience, I
do believe change is also on thehorizon and people are
understanding that it's morethan just that five minute
interaction with your physicianwho's tapping on a keyboard.
We're going to be moving away,where there's going to be

(01:12:52):
ambient technology where you canactually look at your patient
in the eyes and have ameaningful conversation.
We need to get back to thattype of patient care.

Yeah, I definitely think we can do it.
You know it just takes.
I think conversations like thisare very important to inform
people and also kind of givepeople hope and also give them a
direction to point their energytowards.
I'm really thankful for you.
You're definitely a leader inthe industry.
You're definitely shifting a inthe industry.
You're definitely shifting alot of minds and perceptions in
the right direction.
So I just want to thank youagain for coming on, being very

(01:13:28):
generous with your time and thisconversation kind of went in a
different direction than Iexpected, but I'm happy it did.
We kind of ended up more onlifestyle than physician
impairment, which is where westarted.
But that's the way these thingsgo.
But again, dr Scott Ellner,thanks so much for coming on.

Thanks for having me, Parker.

Hey everyone.
That's all for today's show.
I want to thank you so much forstopping by and watching,
especially if you've made it allthe way to this point.
If you'd like to be notifiedwhen new episodes are going to
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(01:14:07):
That website will also belinked in the description.
As always, likes, shares,comments are a huge help to me
and to this channel and to theshow.
So any of that you can do Iwould really appreciate.
And again, thank you so muchfor watching.
I'll see you next time.

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