Episode 065: With Great Power Comes Professional Responsibility

Speaker 1: You are listening to Your Practice Made Perfect; support, protection, and advice for practicing medical professionals brought to you by SVMIC.

Brian: Thank you for joining us today. My name is Brian Fortenberry and on today's episode we're going to be talking about physician professionalism, medical professionalism, and joining us today to help us with that is Dr. Scott Fowler. Dr. Fowler, welcome.

Dr. Fowler: Thank you very much, Brian. I'm happy to be here and this is a topic that's near and dear to my heart, so thank you for having me.

Brian: Well, absolutely. I appreciate you taking the time to join us and talk about this really incredibly important topic, certainly in the ever-changing role of healthcare as we see it today. Before we really jump in, tell our listeners a little bit about yourself, about your background, and some of the things you've done.

Dr. Fowler: Yeah, I'm the president and CEO of Holston Medical Group, which is a multispecialty group here. But getting here, I grew up in New Orleans, Louisiana. I went to college at a small college in Indiana and got very, very interested in college with philosophy and with the ideas around why people do what they do and what we can know. So, I came out of college really with an interest in philosophy but also a very practical desire to do something in my life. And at that point I decided that I really did want to study professionally in some professional pursuit. And, at the time, there were programs out there for JDMDs, so people that went to law school and medical school. And so I did that back to back, entered those programs, got my law degree first and then went on to medical school.

And after graduation, and getting my license, and doing my internships, I practiced both for a period of about four years. I practiced it an emergency rooms and I practiced with a law firm, mainly doing business law. But during that time I think I really did develop this idea that the cornerstone of our healthcare system especially, and it's true about the legal system as well. So it's something that lawyers and doctors certainly share, which by the way, things we share, I try to emphasize because most of the time you have people on different sides of the equation there but I did realize that it's a cornerstone of not only what makes people want to do it or make them good at it, but it also professionalism or the ideas that philosophy can bring to these occupations, which would just be occupations if it wasn't for these notions of professionalism.

So, that's where it started. I fell in love subsequently really with the idea of just practicing medicine and I moved up here to northeast Tennessee tri cities, open my own practice of OBGYN. I think I've delivered thousands and thousands of babies in my practice, but it really was a practice about me trying to do what I really wanted to do in my life. So that was my heart's desire. My goal was to practice medicine and I did it for a long time here.

In about 2005 the multispecialty group that was in this area, which is Holston Medical Group, was undergoing some changes around its leadership and I got interested in how that could play a role. At the time, there was a lot of consolidation, hospitals were beginning to employ doctors, and so I got involved with the multispecialty group and actually merged my OBGYN practice in with that, we had multiple docs in our practice. And after that they started tapping me, I think because of my legal background. And in 2010 I became the CEO of the company. So I've been the president since early of 2010 until now. So, that's my background.

Brian: Holston Medical Group, like you said, a big player certainly in east Tennessee, but really all of this region. Tell us a little more about Holston Medical Group, maybe for listeners that aren't completely familiar with that.

Dr. Fowler: Sure. So Holston Medical Group is a very large multi specialty group located in northeast Tennessee and southwest Virginia. Part of the reason I actually moved up to this area was because I felt like this would be a great place for me to get a chance to exercise my medical abilities because it was a place where, well the Appalachian region itself, as you know, it has some challenges. It has challenges in terms of economics and different things like that, but it really has incredible opportunity to improve the health of the people that are up here. This is an area that has high risk populations and this goes back to the formation of Holston Medical Group.

Holston Medical Group was formed by grant from the Robert Woods Johnson Foundation in 1977 when this region was really, really underserved. And so, some of the local docs that were here really the founders of Holston medical group knew that they needed to get something to bring doctors into the area.

So they went to the Robert Woods Johnson Foundation and they got a grant, I believe it was about $600,000 back in 1977. And they used that grant to bring four or five family docs into this region. And that really is where Holston medical group comes from. So the DNA of the group is very patient centric, very focused on our community and the region. And from that HMG has grown to become about 160 providers. We have multiple offices. We span all the way from Lebanon, Virginia, all the way down to near Morristown. So, a couple hours drive from one side to the other. And we've also been able to develop some of our ideas around patient centric care to include the changes that are happening in healthcare now with value based contracting. So, we have pretty much all of our patients in value based contracts. So that's it. We care for about 200,000 patients. There's about 600,000 in our region, so about a third of all the patients in our region are, we take care of. So, I'm proud to be a part of it. It's a great company.

Brian: Absolutely. That is, like I said, a huge player, not only in Tennessee but in this region of the country. And so therefore really you have the opportunity to be able to put into practice a lot of the professionalism things that we're going to talk about today. And to that point, let's start giving a broad overlook I guess at what is your definition or what do you call physician professionalism?

Dr. Fowler: I think what you have to understand about medicine, and it's true about law, so I want to bring this idea that there is something specifically very important that's different in medicine than it is in many, many other occupations. And there are other occupations that may use the term professional to describe those people. What professionalism really is, is a recognition that you're in a bargaining position, vis-a-vis the person that you're supposed to be taking care of or you're supposed to be responsible for. You're in a position where the bargaining position is such that unless you're very intent on putting that person well before yourself and before other things, that can allow you to very easily put yourself first in front of the patient. So, that happens in law and everybody knows the lawyers are supposed to be making a lot of decisions that are focused on what are the rights of their clients.

But it's true in medicine too, and I think it gets lost a little more easily in medicine. When you become a doctor, you know this from the start. You know that when you raise your hand and you take the oath, the oath is to above all do no harm, to put your patient first, to recognize that the right to practice medicine is something that's given to you. You earned the right to stand in line, but in the end society makes a covenant with you and says, look, you have all this information, you have all this knowledge, and now we're going to give you a license that gives you a monopoly, and what we're asking you to do in return is promise us that you'll recognize the practice of medicine is not a business. It's not a trade, it's a calling, and it's about exercising a very complex combination of science and art and getting along with patients in a way that it will benefit you, there's no question professionalism makes the practice of medicine what it is, but it ultimately benefits the patient in society.

And the only other versions of medical care or purely business versions are medical industrial versions where patients are widgets and doctors are laborers, and those are very nonproductive, both from the point of view of quality and the point of view of satisfaction for patients and for doctors. So, that's my definition of professionalism. It's really a recognition that you have received something and you've, you made an oath to profess means to promise. So a professional promise is very different. For instance, in a labor union, you have a bunch of people to get together in a society or in a group, their interest is themselves, they are there to advocate for themselves. They're there to advocate for better pay, better working hours, things like that.

A profession is also an aggregation, but it's an aggregation where what you're doing is you're advocating for somebody other than yourself. You're actually advocating for the patient. And to do that, you have to recognize that there are several parts. And so, the second part of professionalism is to realize it's an oath, but it's also to realize that it's more than an oath just to the patient. It's an oath to put the patient first, but in order to do that, you also have to put the profession, you have to recognize your relationship with the other professionals that are in the care models with you is just as important as your relationship with the patient. So you can't let that get interrupted, dis-coordinated anymore than you can your care with the patient.

And then lastly, it's an oath that you took all together, you and the rest of your colleagues to care for everybody. It's with society. It's not about, does somebody have insurance and does somebody not. So, ultimately, we have to figure out together with society how this thing's going to work. So that's long winded. It is a long winded way to say, this is the cornerstone. Without this, there is no profession of medicine. It doesn't exist. And professionalism is the thing that makes medicine work. It's the cornerstone.

Brian: I was thinking when you were talking about physicians and lawyers as well, and you understanding both ends. When you have a client, as far as a lawyer is concerned or a patient as a doctor's concern, ultimately they're both customers.

Dr. Fowler: Yes.

Brian: And they are coming to you, in particular, a physician when they need something that they can't provide for themselves. So they come with vulnerabilities, they come with expectations, but they're saying, I can't take care of this, I need you to. So they're very vulnerable and they're really having to hand over a lot of control to another person And that professionalism really needs to come in to comfort that person, I would think.

Dr. Fowler: No, absolutely. It doesn't work otherwise. And I tell a story about when I first put on a light jacket after I'd finished medical school and, I think I was still a student quite frankly, but I walked into a room and there were a lot of people moving around in the room, but it was an older woman and she was pretty sick and there was a lot of discussion about what wAs going on with her. But at the end you're like medical students do I, I stayed in the room after everybody else left to do whatever the things were that I was going to do And she called me over. And I had the short white coat on back then. That's what students wore, but there was a light coat.

And she called me over and she said, "Doc, what do you think I ought to do? You heard all of this, what do you think I ought to do?" And I'm sitting there thinking, listen, I'm a medical student, okay, why you're asking me this incredibly important question about your life and you've got to make this decision. And when you put that coat on, you didn't earn it, it got given to you. The patients understand and respect you because you're in the banner of professionalism and you're absolutely right, if you let, for a minute, if you let your guard drop and you fail to recognize that they are putting their life in your hands basically, and they do it willingly because they expect the return and the return has to be there. There can't even be the appearance that there's impropriety in what you're trying to do there. So, I agree with you. And it's very special and it is, lawyers do have this too and there are other things, but for medicine, without it, the whole thing falls apart. It becomes a charlatan. It becomes snake oil salesman. It becomes people trying to figure out how many of this they can do and how many of that they can do to make money.

And look, medicine has a business. In other words, you can't sustain anything in a marketplace unless you figure out how to run it as a business.

Brian: Absolutely.

Dr. Fowler: But medicine is not at its heart a business. It's something that has to stand above that. And it's like I tell my colleagues here and we all agree on this, if we can put the patient first, if we can recognize that's how we do our job well, all the rest of it comes. Society actually wants doctors to have status. They give it to them. Doctor's don't earn it, they just get it by being a doctor. They want doctors to make good money. They don't want ... they're not making decisions about that. They expect highly educated people who are out there that they're calling on to have money, to live their lives and to have good status in their lives.

So, we don't have to struggle for that. That will be there. And it always has been there. We just have to respect that the way we earn that is quite frankly, by being professionals.

Brian: Absolutely. We've hit on this to some extent, but why is this approach so successful? Because it obviously is and what are some of the outcomes associated with this?

Dr. Fowler: The Approach is successful because it's the way the system was designed. So, it has built into it, it already has the licensing, the society giving this thing over to doc. So there's power in it. By reclaiming the professional model, you create a lot of opportunity to be successful. And let me suggest two ways that it immediately impacts what you do when you recognize it, you talk about it. And look, I'm not saying that anybody's not a professional, what I'm saying is, is that this is something that has to be understood and nurtured for medicine to work. And we are in a society where medicine, quite frankly, there's a lot of evidence it doesn't work very well right now.

There's a lot of evidence it's too expensive, there's a lot of evidence people get things they don't need on a regular basis, there's a lot of evidence that that actually hurts people. Not only does it cost more, but it actually hurts people. So, one of the first things you find out is that as a physician, your life improves dramatically because you remember what it was that you became a physician for.

Brian: Right.

Dr. Fowler: The reinvigorating professionalism as a guiding light in how you move forward in healthcare has two real immediate effects. One is it really begins to combat some of the burnout that we see, especially amongst doctors right now. Doctors are inundated with reporting and all kinds of things that don't appear to have much to do with patient care. A lot of administrative burden, things that, quite frankly, doctors didn't go into medicine to do. That with just the workloads that are required and the 24 seven approach is really having doctors run for the hills a little bit and burnouts a driving factor for that and it certainly interferes with us delivering the best care.

So, professionalism does counteract burnout significantly, almost from the time you start talking about it. We started a foundation for professionalism down here and began it just inviting doctors, just come and let's talk about what's going on and about who we are and what we're supposed to be doing and you can just see the eyes light up.

Brian: That's a fantastic idea just having that comradery that is more than just passing each other in a hall. That is a fantastic idea.

Dr. Fowler: It is important. I think a lot of places, they know that's valuable and they're starting to try to figure it out, but they don't know why it's valuable. And why it's really truly valuable is we have an understanding that we do fit this model of professionalism, that we do actually owe a duty, that it is about not only not doing things that are in proprietary, it's about not even appearing to have conflicts of interest with our patients. It's about understanding what the professional model really is. How is it impacted by employment models? How's it impacted by staff medical models? There's a lot. What does it mean in terms of our relationship with each other as well as society and what duties do we really have?

I think a lot of the forces that have driven a fee for service model of care in America, and a lot of that's resulted in the problems we see today in terms of some of our poor performance on some quality issues as well as the cost. The cost in the United States is really out. So, I think you see some immediate understanding that there is a light at the end of the tunnel and that does combat burnout. It re-establishes the physician as really the one who’s supposed to have control. We're supposed to have at our fingertips, in a sense, what we need to properly advise our patients and help our patients understand things so they can make really good decisions about things.

A well informed patient should make the decisions that a doctor would make. If we're educating them appropriately and we look at what doctors do, and we look at what patients do, we should see some, obviously there's cultural issues, but we should see some similarity in choice and we don't. We see that doctors don't do the same things that patients are doing. They don't get admitted at the last week of their life and get intubated. They don't do cancer treatments that a lot of patients do do. They don't have prostate surgeries. They don't get cath and stent at the same rates that patients do.

So, not to point a finger at any particular thing other than to say, there's obviously other forces that are acting in our current model that drive that utilization curve. So, that's the first thing. The second thing is, is that it turns out that if you focus on the right issues, which are putting patients first and building models which allow you to have control over making sure that the patients actually do get put first, some of which we can talk about that we've done at HMG But when you do that, you find out that, not only do you not have as much burnout, but you actually perform better, your financial sustainability improves, You don't have to see 85 patients a day, you can cut down to reasonable amounts.

So, I think that's what we've seen. If you look at the data, it's not just us, it's really everybody who's moved towards this value based model successfully has jettisoned a lot of the old model, it's not the old model just doing things better like they've always done. It's actually these new models that are developing. They're all having success if you separate them outright. The average cost of patient care and models where there's a professional association of relationships, best way I can put it, where patients actually get put first and decisions are being made around that, you actually do see costs fall.

Brian: Wow.

Dr. Fowler: Yeah. And you also see quality improved. So less money for more. That's what you get out of this.

Brian: And that's what everybody in healthcare shooting for right now too is improved quality, decreased price or cost.

Dr. Fowler: That's right. And I guess my assertion is that you do that by refocusing on the principles of what it means to have a professional model of medical care. And the lawyers do this quite frequently by the way. Lawyers write law so they've codified a code of professional responsibility that really does try to address professionalism issues. Doctors, we'd talk about beneficence and we talk a lot about ethics and what we should do in different circumstances, we tend to undervalue the basic discussion of how it is that we're here and why is it that we're here. Why is it that doctors have a monopoly on medical care? Why is it that other people aren't allowed to practice medicine?

Society has to at some level say that you get this right and they asked for something in return, and sometimes we don't recognize. We think because we went to school, we earned it, that's actually not true. What you got when you went to school was you met some requirements. What actually happened was you got given way more than your earned and that's part of understanding professionalism. Yeah.

Brian: You were given an opportunity really is which you were given, if anything. That's it. You've already kind of hit on this, but I want you to expand on it a little bit about, how do you make this work? And by that I mean, what types of tools or things are really important to be able to take this professional model approach?

Dr. Fowler: Yeah. I think the beginning of it is just sitting down and understanding what it really means. And what it really means is that you're not acting professionally, you're not actually doing your job if you're not engaging yourself in an understanding that you have to put the patient first. It's not about anything else first. So, I think that fundamentally starts to move the equation. When you do that, you start asking the question from that perspective. So I talk about the light at the end of the tunnel. You have a light to run to because light to run two is always going to be, does this make sense? Is this in the overall scheme of everything I've learned, and everything I know, and the art and the science of what I'm trying to do?

Is this the right thing for me to do? And when you put it in the context of professionalism, if it's a professionalism point of view, the answer actually pops up, whereas otherwise it would be very complex and you would really have a whole lot of people talking about a whole lot of stuff. So, let's take, for instance, the ability to exchange patient records with other doctors who are caring for your patient.

Brian: Sure. Like EHRs.

Dr. Fowler: EHRs, or let's say that there's a doctor who's a primary care doctor, but this patient has other problems, so they have a cardiologist, they have a rheumatologists, they have a urologist, they have these other docs and each one of those doctors is operating in their own little pod, their own little fee for service pod right now for the most part. And you asked yourself the question, now, should we try to make sure that everybody who's taking care of the same patient actually is operating off a common understanding of the patient? In other words, a common record, in a sense.

Do we all know what medicines they're on. Do we all know what the other guy did? Do we actually know what happened to the patient, go to an urgent care in between the time they saw all of us, are we actually talking to each other about the patient? Does the patient know the things that they ... Have they been educated around these types of things?

So, if you look at it from the point of view of professionalism, there's an immediate answer and that's we live in a time of great transformation in terms of IT technology, why is it that we all have a separate EHR, we all have separate records, none of them talk to each other? It makes sense if we're all doctors and we're all being professionals, that we would all work together to solve that problem. We would take control of it. It wouldn't be a hospital problem. It wouldn't be a government problem. It wouldn't be any of that. We certainly would need money to address it, so we'd have to figure that out. But it wouldn't be about whether we should address it or not. And that's what professionalism I think really does.

For instance, in our local area, we've managed to motivate the doctors to all connect to a common interoperability platform, so it doesn't matter what EHR you're on and it's real time so that when a patient touches somebody who's on that system and it's only available to the people caring for the patient. This isn't about pharmaceutical company data or any of that stuff, it's about patient care. If that patient is my patient and I'm seeing them, and there's another doctor who's also the doctor for that patient, those are the only people that need, this is patient care information. But we know immediately, I know when that patient hit the urgent care center. I have the ability to do that. So, now I can focus on my group of patients and say, I know I'm worried about Ms. Jones. I know Ms. Jones well, I've seen her for the last five years of her life. I know exactly what's going on with her and she's in the emergency room.

She's in the emergency room with a doctor who may be has never met her before, and he may not have any of her records available, right?

Brian: Exactly.

Dr. Fowler: Now I can start to begin to apply because now I have power, I have some control to do the thing for my patient that my professionalism tells me I should be trying to do and now I've removed the barrier to do it. So, we've done that here. We have a cloud based model. It can connect any EHR to any EHR, the docs had bought into it. We've convinced a lot of the other sources of information for these patients, medical sources like visits to the emergency room, we've convinced people to give us that data in real-time way.

So, that's an example. Other examples are working together to coordinate specific problems that patients have like polypharmacy. We have patients who are on 17 different medications, and when they go to the pharmacy, the pharmacy changes them because their insurance contract changed, or nobody can afford 17 medicines. I mean, there's just no way. And people are making choices and they're choosing the blue pill instead of the green pill because they don't know what else to do. Yeah. So there's a huge segment right now of our population who quite frankly isn't getting really taken care of because our model can't. They fall through the cracks because we're fragmented and we don't stratify and we don't focus our attention or we can't quite frank. It's nobody's fault. It's the fault of the design.

The professionalism design starts to move those out of the way, and it starts to recognize we do have a medical industrial complex out there that consumes $3 trillion a year, probably three times what most other countries do, certainly two, for providing pretty much similar levels of care, sometimes worse, sometimes better, but for the most part, we're spending a lot more money and that complex is built up by all these barriers to good patient focused care.

That's why when you get the think-tanks at Harvard and whatnot, they identify this very quickly. They identify the problems at the provider level. The problem is about having information. The problem is about the relationship with the patient that engages the provider and the patient in a common model. The problem is about controlling some of these cost issues which are high profit for a lot of people.

Brian: Right.

Dr. Fowler: I think the end result is the tools that are there are the professional model itself, breaking the barriers which are currently in place that were put in place in order to build a very fragmented fee for service system out there that now has become unsustainable, so we have an opportunity and that's all it is, it's an opportunity. If we don't do it, I suspect that most of the protections that we currently receive from society, in terms of being professionals, society gives us huge latitude. Doctors are the ones that write prescriptions, doctors are ones who can bill for medical services, those things will erode if they're not getting back what they're giving, they're going to begin to allow, well, let's just let the system be controlled by something else and ultimately it becomes nationalized I suppose in the end, the government just says, we can't deal with this.

I do think there's a huge opportunity to reinvent an exceptional model of care, specifically in America around this idea of, well, professionalism has been there from the beginning. It's reigniting it. It's giving back to the relationship with the patient. It's putting the patient back in the center and it's exercising the power and control that society's given to physicians, and when I say physicians, I want to emphasize it's a team of people taking care of these patients. These are complicated patients, but they're all together and they're all focused on the patient first.

Brian: The things that are jumping out to me that just really makes sense is, one, patient focused care to empower the patient to really have a say in their healthcare. And then the other thing is physicians not just sitting on the sidelines waiting on someone else to fix the problems that they know the best. It's getting involved and being active enough to ... like you have over in eastern Tennessee with getting everyone on the same page as far as understanding the continuity of care. It's being innovative and jumping out there and being willing to jump in and do something about it.

Dr. Fowler: That's it, and understanding it's our duty. This isn't an optional, I think this'll be a good business decision. It's what we're supposed to be doing as professionals and it's what makes our life, it's what we went to medical school for, quite frankly, it's what makes the life of a doctor something extra special and I'm afraid, not only are we not maximizing what we can do for our patients in our society, we're not maximizing what society's already given us.

Brian: Absolutely.

Dr. Fowler: In the end, it's about choice, and knowledge, and understanding that a patient can acquire from a trusted advisor that they know has no conflicts of interest, doesn't even have the appearance of a conflict, and is working at least to the best of their ability in their best interest.

Brian: Dr. Fowler, I appreciate the time that you've given us. You've given us a tremendous amount of information, really, really good information that I think many of our listeners will find very valuable. Thanks for taking the time to do this with us today.

Dr. Fowler: Thank you very much, I've enjoyed it.

Speaker 1: Thank you for listening to this episode of your practice made perfect with your host Brian Fortenberry. Listen to more episodes, subscribe to the podcast and find show notes at svmic.com/podcast.

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