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[00:00:00] Stacey Richter: Episode 438, "Recognizing Cognitive Dissonance and Thinking About How to Overcome It When in the Belly of the Beast". Today I speak with Dr. John Lee. 

American Healthcare Entrepreneurs and Executives You Want to Know, Talking, Relentlessly Seeking Value. 

Cognitive dissonance is kind of rampant in the healthcare industry. Cognitive dissonance is when what someone winds up doing, their actions, are in conflict with what they believe in. Cognitive dissonance also can mean when someone holds two contradictory beliefs at the same time.

The Hypothetical Dilemma of Healthcare Professionals

[00:00:47] Stacey Richter: Like, let's say a person believes they want to do well by patients. But their performance review depends on, as just one example, making care less affordable for patients. But somehow, this individual is able to conclude that what they're doing is a net neutral or a net positive despite, in this hypothetical, let's just say, obvious indications that it is not.

In this hypothetical, there are, say, clear facts that show that what this person is up to is indisputably a problem for patients. But yet at every opportunity, this person talks about their commitment to patients. This rationalization, or earmuffs don't look, don't see, is cognitive dissonance. 

The Impact of Cognitive Dissonance on Clinicians

[00:01:26] Stacey Richter: Now, it's harder to engage in cognitive dissonance the closer you are to patients, because you see the impact up close.

This is probably why moral injury and burnout is most associated with clinicians who are seeing patients. Unless these at the bedside clinicians enjoy a robust lack of self awareness, those who are seeing patients don't a lot of times have the luxury of pretending that what is going on is good for patients when they can see with their own two eyes that it is not good for patients. 

The further from the exam room or the community, however, the easier it is to not acknowledge the downstream impact. If you can even figure out what that downstream impact is, which is also worthy of being mentioned, when the machine is really big, sometimes it's legitimately difficult to connect the dots all the way down the line to the customers, members or patients.

Kate Wolin talked about this in an episode a couple of weeks ago. But this whole dissonance exploration was a big reason why actually I created my manifesto, which is episode 400, because almost everything that we do in healthcare wherein we are making money or helping someone else make money is dissonant to some degree.

And it literally keeps me up at night contemplating how much dissonance is too much dissonance or how much self interest, is too much self interest. This is tough, subjective stuff. So again, episode 400 for more on at least how I think about this. 

Exploring Solutions to Healthcare's Cognitive Dissonance

[00:02:52] Stacey Richter: But today I am talking with Dr. John Lee about what to do in the face of all this when working in the, as I call it, the belly of the beast, working for a large healthcare organization such as a hospital.

Because hospitals sometimes, and we certainly do not want to put all hospitals in the same category, they are a wildly diverse bunch, but sometimes some people at some hospitals do some things which are not things I think they should be doing anyway. They're fairly egregious breaches of trust, actually.

But yet within that same organization, you have doctors and other clinicians or others. Who are working really hard to serve patients as best they can. This is the real world that we're talking about. And the question of the day is, so now what? While it would be amazing if someday we build a whole new health system that didn't include some people doing things that I don't think they should be doing, that day is not today.

And it's not tomorrow. I'm going to hope that there's other people in our village who are full on doing the disruption thing. But if we're not able to do that personally, for whatever reason, but we still want to inch forward within the existing environment and do the things that make us feel like we're achieving our mission, what's the best way to think about this? 

Dr. John Lee's Insights on Navigating Healthcare Challenges

[00:04:08] Stacey Richter: That is what I asked Dr. John Lee, and that's what our conversation is about today. Summing up his advice, which is really good advice, Dr. Lee talks at length about how it's so important to celebrate the small wins and feel good about care that is a little bit better than it was six months ago.

He talks about acknowledging that you can't do everything. He talks about incremental improvement that helps both patients but also colleagues, and that's not insignificant to really consciously consider how to work together and help to support each other. 

Look, I just finished reading a post on LinkedIn about toxic medical culture and just how brutal and cruel some physicians and physician leaders and others can be to their colleagues.

Ann Richardson writes about topics like this a lot. Follow her on LinkedIn if you're interested. So does J. Michael Connors. But just saying, it's pretty cognitively dissonant to talk about like the potential of team based care and then condone or engage in toxic behavior with those same team members.

There's like 90 studies on this whole topic linked to a book in the show notes.

The Role of Culture and Community in Healthcare Improvement

[00:05:14] Stacey Richter: But bottom line, fixing cognitively dissonant paradigms in any sort of durable or scalable way is for sure going to require a culture that inspires constructive criticism, innovation and collaboration. It also requires, and this is Dr. Lee's last piece of advice, it's really important to seek out like minded individuals as sounding boards and as a support network to commit to supporting each other. And I hope, all of you, that you feel like you've found your tribe here at Relentless Health Value. You guys are an amazing bunch, so know that and don't hesitate to reach out to each other when you need help.

And I know, I know, I need to create a directory so you can all hook up more easily, so do subscribe to the weekly email because I am inching closer to finally managing to get this done and you won't know about it unless you're subscribed, go to the website. You will be hit with a pop up window fast enough, but back to easing cognitive dissonance and the why here.

I thought Michelle Burnaby put how much of a difference the right culture can make for patients and those who work together really eloquently recently. This is a great why, since we spend so much of our life at work. She wrote, each day we come together ready to roll up our sleeves, committed to our own growth, our boundaries and our teamwork.

This collective dedication resonates throughout our organization and is, I trust, felt by our clients and our partners. 

Practical Steps and Personal Experiences in Healthcare Innovation

[00:06:40] Stacey Richter: In the conversation that follows, Dr. John Lee offers a really nice array of examples of incremental, in the belly of the beast, stuff that might be possible in the real world, at least in the bellies of some beasts, plus some other points of contemplation. 

Dr. Lee is an ER doc, emergency room doc by training, who is also an informaticist and chief medical information officer. I can tell you from personal experience that Dr. Lee is one of the most creative and pragmatic problem solvers that I have encountered. He says he's dedicated to trying to help move the ball forward and changing our healthcare system using information technology and using our ability to be far more transparent with the things that we try to do in a positive way in healthcare. 

So without further ado, my name is Stacey Richter and this podcast is sponsored by Aventria Health Group. 

Dr. John Lee, welcome to Relentless Health Value. 

[00:07:29] Dr. John Lee: Thank you so much for having me. This is the highlight of my day. 

[00:07:32] Stacey Richter: Well, it is the highlight of my day to speak with you, my friend.

Why don't we just start out with if you're thinking about cognitive dissonance, how do you think about it? What is it relative to the healthcare industry? 

[00:07:43] Dr. John Lee: There's a lot of rhetoric, saying, we have to change how we do things. Once people who buy into that get into the system and try to change the system, particularly from the inside, they're often overwhelmed by the tide of the momentum continuing to push the system in essentially in the same way that it has been continuing to go for the past several decades.

The cognitive dissonance that you're describing is the feeling that I wish we could do more, but the system just won't let us. And there's many people who've talked a lot about this, but just from a personal perspective, it's sometimes can be very frustrating. And one of the reasons why I gravitated toward your podcast, because it was a different tribe that I could feel like I could belong to, that at least maybe I can't make that sort of grand scale impact that I want to make, but at least I can be surrounded by other people who are of a like mind.

[00:08:40] Stacey Richter: Well, I appreciate that. And that is actually a goal of the podcast, to provide a sort of community that can wrap around and give some bolstering and comfort to those who may feel very alone. For maybe the reasons that we can talk about right now, you have a system that after all this time, very fee for service oriented.

What are the incentives that start to wind up bearing down on individuals who are operating in the system as a clinician or as someone who is working directly with patients? 

[00:09:14] Dr. John Lee: There was this one presentation given by an internal medicine physician. And he and his team stood up a really, really good heart failure program, high touch, lots of people making phone calls, touching base with really sick, chronically ill heart failure patients.

And they were really successful. They were really successful in reducing the number of hospitalizations that these heart failure patients were having by almost like a third or a half or something like that. And it was a fantastic presentation. I went up to him afterward, congratulated him, shook his hand, and his comment afterward was, yeah, I didn't want to say it during the conversation.

He looked a little bit downcast. And he said, yeah, we have to actually sunset this program because it is too successful. Well, first of all, number one, it's very resource intensive, so it costs a lot of money. But the commentary that he made was that, my CEO told me that we have to stop the program because it's reducing heart failure admissions too much.

It's costing the hospital money. And actually, I just recently listened to your podcast with Scott Conard, who talked about how in a similar way, in a larger sense, his clinics were so, so successful that the healthcare system bought his clinics and then shut it down because they were reducing the number of hospitalizations.

That's the sort of cognitive dissonance that is so frustrating to people who want to try to actually improve our system. 

[00:10:39] Stacey Richter: Paraphrasing what you said there, so here you are, and here the doctor who set up that heart failure program was, here's Dr. Scott Conard. There are so many examples of great clinicians and very mission driven individuals across the country. Jodelyn Owen is another one with maternal health. Rob Andrews also talks about this on the show, wherein the way that the money flows right now, you don't get paid a lot for preventing anything. Despite all the hoopla about value based care, 1 percent of heart failure patients are on optimal medical therapy in this country.

I can cite stats like that off the top of my head because I was so shocked. Not only do we not have chronic disease patients who are being treated in ways that have been demonstrated to work, but then we have a system that is actively kneecapping anybody that's trying to do that. The money doesn't work.

[00:11:36] Dr. John Lee: Yeah. And I would say that the sorts of conversations that I had with that internal medicine physician is probably more an exception rather than the rule. Most healthcare systems are just obliviously ambivalent and satisfied with doing things the current way that they're doing it. And the technology that then they apply then is applied to basically maintaining the current status quo, but just doing it faster or doing it more efficiently.

[00:12:04] Stacey Richter: Well, it's interesting because I also was at a physician summit a couple of years ago, and I listened to a doc who also stood up a heart failure program to prevent readmissions, and it was also very successful, and it also got shut down. And I think the reason given was that too many readmissions were being avoided.

And there was more money in those readmissions than in the paltry CMS fines. Actually, you know, the show with Dr. Rishi Wadhera gets into this in depth. And yeah, he cites a whole study that also bears this out. So for sure, you definitely have system level factors that start pressing down on individuals.

[00:12:43] Dr. John Lee: But, so, I know of many of my colleagues who are very focused on RVUs and the volume of services that they produced. But I also know that they're really good docs who really, really care about their patients. But they’re existing within an environment that just induces that sort of behavior so that it's less of an issue where they're trying to... They're not trying to game the system, but the system has almost gamed them, and you can't really blame most of the people for doing the things the way that they're doing them.

And what we have to do is try to actually change the system, but a third of healthcare waste is somebody else's profit. That profit buys a lot of influence. 

[00:13:29] Stacey Richter: Let's talk about how these systemic pressures really press down on individuals. You know, there is an epidemic of burnout in this country. As I've heard it said, burnout is moral injury in a cheap Halloween costume.

Maybe moral injury is another word for cognitive dissonance, right? It's just what happens when personal values and personal missions collide with these systemic level pressures. So if I'm just making a list of things that create this cognitive dissonance. It's the way the comp models work. You mentioned RVUs.

[00:14:05] Dr. John Lee: Yeah, you know, let me kind of paint a picture of something that has been a theme, particularly among some of my ambulatory and primary care based colleagues. They are constantly being pushed harder and harder to see more and more patients to increase that volume based revenue. And at the same time, they have all these sorts of quality based check marks that they are required to fulfill as they work harder and harder and faster and faster.

Before, instead of seeing 25 patients in a day, the organization was okay having them see 20 patients in a day, and it may have been still fee for service, they still had some wiggle room to talk to the patient about other stuff and connect with the patient so that that sort of interaction assuaged some of that moral injury that was occurring.

Now you're squeezing all that stuff out and it all just becomes like you're a CPT, RVU machine. That's where a lot of the burnout comes from. And I think from a technology perspective, there is the ability to actually change that paradigm, to introduce more team based care, to actually create very proactive mechanisms so that the primary physician who's responsible for a particular patient, is may not necessarily have to spend a ton of time with that patient because he has an entire team surrounding him to support how that physician interacts with that patient so that if they do have that interaction with the patient, they actually feel like they're actually moving the ball forward and improving that patient's life, or I guess to use the Peter Attia term that improve that patient's health span.

The Power of Small Wins and Community Support

[00:15:41] Stacey Richter: To underscore that point, my mother made an appointment with her doctor. When she was on the phone making the appointment, she was told, you're not allowed to bring up anything else but your chief complaint while you're in the room seeing the doctor. 

[00:15:56] Dr. John Lee: But those sorts of things are what helps assuage and inoculate us against that moral injury.

We are people. We want to interact and feel like we're connecting with the people that we're serving. The way that the system has developed and quote unquote matured over the past few years has really taken that away from us. 

[00:16:16] Stacey Richter: And just to state the obvious here, another word for connects with people is to build a relationship that has trust with people.

So there's obviously consequences on both sides of the room there. In which you have a physician who is being treated or feels like an RVU machine, a CPT code machine, as you just said. But on the other side, you've got a patient who's like, I guess I'm a widget too. So we have a system at this juncture that's pressing people into these modes that reduce the human aspect reinterpreting what you just said.

Layer onto that the idea, which could be especially demoralizing to someone such as yourself, who can see a way forward. Who can see, wow, we could use technology in this way, we could do this, we could do that, there's so many ways that I could see to improve this, and then you have a system that's like, nah, I think not, right. Like I could also see how that would be frustrating to the good people, you know, like the people that wanted to try to figure out how to fix it and no one is interested.

[00:17:26] Dr. John Lee: And one of the things that I've sort of migrated to in my thinking is that I'm not gonna make that wholesale massive change. What I can do is nibble around the edges, help things in little ways, and even if I get just a little win, hopefully I will be that one little win compounded with other little wins that other people make as we try to improve our healthcare system. 

[00:17:49] Stacey Richter: It's interesting how you put that because in the show with Barbara Wachsman, she was advising those who wished to sell something to employers to not nibble around the edges, but to do something big enough to get an employer's attention. I know some of you are thinking about that right now.

And I'd say that both of these things can be true simultaneously because Dr. Lee, what you're talking about is working from within the belly of the beast, surrounded on all sides by a giant institution. So for you, the best path forward might be small things that make a difference right now for patients and your colleagues.

And I feel like I'd be remiss not to mention that this is a very different use case than what Barbara Wachsman was talking about. What works in some situations as we think about bigger and more disruptive is just not going to work for somebody else. It's just not even possible. Both are kind of solving different problems at different timeframes. And it's these kinds of differences, which is the background why I put together the manifesto that I did, which is episode 400. 

And I've gotten innumerable messages and calls from individuals who said, you know, thank you for helping me put into words what I really feel here. So what I want to hear from you is, okay, you know, now what? How do you make lemonade out of lemons? How do you contemplate still feeling like you're working in alignment with your values and what you want to accomplish despite so many pressures?

You and I have had some conversations earlier where if you come up with something that you'd like to do and then there's all sorts of obstacles in the way, you said it's really easy to become disillusioned. And you were talking about how your advice and your mindset then has to be, okay, in the face of what's going on, what can I do?

What can I accomplish? So how do you think about the incremental improvements that you can realistically make? Or what are some examples of things that you have done? 

[00:19:49] Dr. John Lee: One of the things that I'm really, really proud about is I helped create a system that my fellow emergency physicians, they were actually okay with it.

Unlike many other colleagues around the country, they viewed the system as pretty well designed. And so that for me was that one little thing, moving the ball forward so that we could actually start digitizing some of the data that our system creates in taking care of patients. And in me helping my colleagues be more comfortable with a digital system, now we've created data. 

That data can then inform other tools downstream that can help transform the system. That's the very first step. We can't do anything else without doing that. And then another is just coming up with different ideas. Some of them may not stick. So your podcast with Kenny Cole, within it, he mentioned something about metformin and how people stop taking metformin because of gastrointestinal side effects.

But I know that how that's documented within the system, it's very different based on who documents it and what system they document it in. If we could somehow encapsulate that as a piece of data that's consistent and reliable across systems or across offices or across practitioners. Then you can start aggregating that and then being able to say, okay, these are the things that actually predispose somebody who is on metformin to stop taking it because of gastrointestinal side effects.

And then if you can start encapsulating that as a digital picture, then you can actually start putting into place. Even something simple as, well, we see based on the data that's in your system that you're predisposed to having gastrointestinal side effects. We are going to have somebody call you a week after you start metformin and see how you're doing and see if we can put in some mitigating processes so that you can stay on metformin.

But the first step of that is actually encapsulating that as data. And what I did was I took that podcast, I forwarded it on to some people I knew who are very astute data scientists. And they have a way to actually encapsulate that and encode that into something that is very easily digestible by multiple systems across multiple organizations.

And that's something that would be really valuable. Now, I'm realistic enough to know that putting that out there and kicking that off, that may or may not go anywhere, but I keep trying because that's my makeup. I want to try to help move the ball forward and use technology to actually improve our healthcare system. And that's the sort of thing that I keep trying to do. 

[00:22:21] Stacey Richter: I'm very inspired by you and the initiative that you have when you do stuff like this. It's another thing, but it also might be exactly what is necessary to feel like a difference is being made when you consider how you may help your colleagues.

Like, how do I, within my current role, potentially support colleagues who are trying to figure out how to do right by patients? Which many are, and you give two examples there. One is in your role at the time, and everybody's going to have their own example of this, but you were tasked with building an ER IT infrastructure, the system that you built aligned with what your colleagues needs are, not just what somebody dictated from above.

So you took the time to ensure that the system that you built was going to work for colleagues as well as the hospital system writ large. Which I can definitely see would give a measure of appreciation and pride, rightfully so. And then the second part of this is what do patients really need? You gave the example of the episode with Dr. Kenny Cole from a couple of weeks ago. He talks about just how many patients fail on metformin because they're actually not taking it properly. 

[00:23:30] Dr. John Lee: I'm going to come off as a Stacey Richter fanboy on this, but I'm going to quote another episode that you had. I forgot what the exact quote was, you used a Marcus Aurelius quote.

Something about being happy with the smallest progress. And I think that's what we have to do. Some of us are big names, have big influence, have big personalities, and can do big things. Mark Cuban-ish type things. But others of us, we have to be able to be satisfied with doing the right things that we feel like we can do and be satisfied with that.

[00:24:01] Stacey Richter: Figure out how to support your colleagues. You can figure out how to support patients in whatever ways. What's your advice for someone who might not have the same job as you? 

[00:24:10] Dr. John Lee: One of the teams that I used to work with, I would use this metaphor a lot. Our healthcare system, the dysfunction in our healthcare system is like this enormous boulder stuck on the side of a mountain.

Just one person isn't going to push that boulder down the hill, which is what we need to do. But what we can do is take the little pieces of pebbles around that boulder. If enough of us are taking out enough of those pebbles, at some point that boulder is going to start rocking. And then once that boulder starts rocking, at some point somebody is going to be able to push it.

And then once that boulder starts rolling, it can't be stopped. Because the things that we need to do with our healthcare system all make a ton of sense. Once that logic takes hold and the things that our patients need align with how we actually deliver healthcare, then it's going to be a force that can't be stopped.

I may be being a little bit too optimistic, but that's what I truly firmly believe. 

[00:25:04] Stacey Richter: That's a wonderful way to put this, exactly like you just said. If there's a boulder and we each just take a pebble, then we can really create change in an organic way, even if it's not necessarily some kind of formal, collaborational alignment.

That is, each of us just thinks, what can we do? What are the simple opportunities, I think you've called it. Wherein we could make even a small difference if there's enough people who are thinking that way. Inevitably change will wind up happening just because it's almost creating a zeitgeist of a certain kind.

[00:25:40] Dr. John Lee: Yeah, absolutely. And you know, That's a great way to put it. 

[00:25:43] Stacey Richter: The other thing, here's another word for a zeitgeist, a tipping point. One of the things in that Malcolm Gladwell book, if only 12 percent of individuals are pushing in a certain direction, tipping points happen. It's just, it's amazing how word travels, ideas spread, especially if there's enough people who believe something in their heart of hearts and want to see something happen.

And I do feel like there's so many across the healthcare industry that realize something's gotta give. 

[00:26:11] Dr. John Lee: We just need to be able to push back against that system. And, you know, to use another metaphor, if the current system is a big river pushing us downstream, as difficult as it sounds, we need to reroute that river so it points in a different direction.

[00:26:26] Stacey Richter: So, one of the things that you said was, as we just talked about, Dr. Kenny Cole talked about just how many patients stopped taking metformin because of avoidable gastrointestinal symptoms, and that is something that could be codified if we, A, know it because we have the data, but B, we can build something to disseminate that information.

But what else? Give us some bright spots here, things that people may contemplate. 

[00:26:51] Dr. John Lee: So let's say you're a medical assistant in an office and you see the doctor doing all this labor that you think that you could do. Then maybe suggest, hey, maybe we can do this and take the load off your shoulders, doctor, or to the nurse and feel like you're contributing more.

It could probably positively impact how you feel about your being part of the team and contributing to the patient's care. Also, making the team more effective and efficient. The other thing is to start identifying places where there are waste. And they're all over the place. That sort of identification and the reporting and trying to execute on that sort of observation.

That's an entire project all together, but at least start maybe taking that and injecting kind of that culture of, you know, we shouldn't be really doing this, or there's a different way of approaching this. Why is that printer way over there, 20 feet away from the computer, when everybody goes to that printer for every single patient as we print stuff out, little things can add up to a lot. 

[00:27:55] Stacey Richter: Those are some great examples that have just so much packed into them. One of them is, just make a suggestion. And it's, in a way, a commentary on the healthcare system today that even comes up. We've gotten ourselves into a place where we talk about team based care, but we have to bring up if someone sees something that could be improved, maybe we should talk amongst ourselves.

[00:28:22] Dr. John Lee: Yeah. The unfortunate reality is that there's a lot of healthcare systems, maybe even most of them, that are very hierarchical. The doctor or the c-suite administrator says, we have to do it this way and people have to kind of march in line. I think it would benefit our healthcare system at large if we weren't like that as much.

That if we could actually incorporate the sorts of suggestions or input of the entire team and this is almost an organizational extension of the concept of team based care around a particular patient. But team based care from an organizational perspective, I just wish that a lot of our healthcare systems would absolve themselves of the top down hierarchical approach to managing systems. 

[00:29:07] Stacey Richter: Well, here comes Gen Z and the one thing I've heard about Gen Z is they really don't like hierarchy very much, but in a way, a command and control environment is somewhat antithetical to team-based care, having teams wherein the team feels afraid to speak up and make suggestions because the hierarchical, you know, like those that sit above them are gonna lash out, like, there's a lot of consequences.

[00:29:33] Dr. John Lee: Yeah, it's in their best interest to promote that sort of stuff. 

[00:29:38] Stacey Richter: So maybe contemplate what's the environment? Is there any influence that you might have on the environment that could enable people who are trying to do things in a better way or who may have insight into how to improve?

Can they feel like they can speak up. That's number one. Or number two, if you see something, maybe say something. And I'm not sure if you have any advice for if someone is working in a hierarchical environment and they do see something and they want to say something. I was chatting with Anne Richardson the other day who had just one example after another of times when someone brought up something that was a potential patient problem or was a patient problem.

And the response of the system was actually to blame that individual for the problem. And wow, my heart just started to bleed for some of these really mission driven people getting their faces smashed against the wall for daring to do the right thing on behalf of patients. 

[00:30:36] Dr. John Lee: Well, that's an entire discussion altogether.

I mean, whenever I think about this in the recent history, I consider the Radonda Vaught story. She's a nurse sedating a patient, I think for an MRI, and there were two medications. One was Vecuronium, which is a paralytic, and the other one was Versed. And because both of them started with VE, they were close together in the medication cart.

She was supposed to give Versed to sedate the patient. She gave Vecuronium, which paralyzed the patient. The patient died. She self reported this mistake and then she was criminally prosecuted for doing this. 

[00:31:10] Stacey Richter: This was recent. We'll link to that in the show notes. 

[00:31:14] Dr. John Lee: But this is the sort of thing that needs to stop.

Yes, tragic. Yes, she made a mistake. But I can almost guarantee you that at least one, probably more nurses almost made that same mistake, but they didn't report it. Phew, that was a near miss. I'm going to get on with my day. But imagine if they had reported that and then there were like three or four reports of that.

Somebody noticed and said, Ooh, that would be a really bad mistake to have. So let's systematically try to create, you know, rearrange the medication card or do something. So that, that sort of mistake can't happen in the future. Then that patient wouldn't have died. That nurse would not be facing a prison term.

[00:31:54] Stacey Richter: Wow, that is so horrific. You really have to think through the outcome you're trying to create. Is it to prevent additional deaths or punish a nurse who reported her own mistake? Because in a way, maybe we have to pick one because we can't have both. 

[00:32:11] Dr. John Lee: So this kind of goes to this larger discussion that we're having.

This big system is pushing everybody in a certain direction. I can understand how somebody who's, say, a medical assistant who sees something doesn't want to speak up or they don't feel empowered to contribute to the team. And I hope that people start doing that a little bit more. 

[00:32:32] Stacey Richter: So if we're thinking about constructing our pieces of advice here, the first piece that we talked about was really contemplative of what do patients need?

What's gonna help? Second one is how do you support colleagues? Thinking about both of these two things simultaneously, you had mentioned waste. Where is there waste within the system that could negatively impact patient care? Example of this, there's lots of people not in exam rooms because they're walking around trying to get printouts.

Time is a zero sum situation, so it's certainly a win win. In order to achieve either one of those two aims, it does take trying to figure out how to build an environment that people bring up suggestions to continuously improve. 

[00:33:20] Dr. John Lee: The other piece of this, though, is that you also have to acknowledge that you can't do everything.

And that there are certain capacity constraints, even if you say, suggest that you move that printer, you may not necessarily realize that IT has to come by and they have to rewire all the cables and then they have to remap the printer to it's something that seems simple, often isn't simple. And so I think as somebody who's trying to do stuff like this, you also have to accept the fact that there are certain limitations on what you can do.

There are capacity constraints. And then not necessarily get frustrated about it. 

[00:33:56] Stacey Richter: It may be a lot of steps for some individuals, but it's closer for others. So there's this compromise situation. One of the things we talked about team based care being a part of this and doing things to really support and emphasize the team and the team based care.

So not getting frustrated by that. What's that African proverb? If you want to go fast, go alone. If you want to go far, go together. So, the going far together is always going to take longer. But the other one that you had mentioned was the whole idea of moving this whole transformation thing forward. It's bigger than a boulder, right?

It's probably planet sized. So, we each have to just be happy with what we actually can accomplish. Like, we can't let perfect be the enemy of the good and mental health and just our motivation to keep doing what we're doing on behalf of patients. Let's really feel good about the pebbles that we have pulled out and fixed.

[00:34:59] Dr. John Lee: Yes, absolutely. Otherwise, you'll just get frustrated. 

[00:35:01] Stacey Richter: I do feel like in a lot of environments, it's the really good motivated people who are the ones that wind up leaving. I feel like this is a really important conversation to have because it's exactly those individuals, you know, the ones that are listening to this show that we really need to continue to inspire and be inspired in the face of all these contrary forces and just BS because it's this crew that's going to transform healthcare if anybody's going to do it.

[00:35:26] Dr. John Lee: Well, and I think also one of the things that just came to mind is It is really helpful to have like minded individuals to be able to be sounding boards for other like minded individuals. One of the things that I would love for you to do is create some sort of mechanism for people to connect and communicate with each other who are of like mind so that I don't feel like I'm the only Relentless Health Value person in my organization.

There may be some others. And I've certainly encountered others who have in some of the work that I do around the country, I mentioned your podcast and they said, oh yeah, I love talking to Stacey. And then that creates almost kind of an instant bond that, yeah, we know what we want to try to do. And we know that we're both frustrated.

And we also know that if we get too frustrated, we can count on each other to talk us off the cliff. 

[00:36:15] Stacey Richter: That's such a lovely way to put it. And it really just emphasizes the importance of community, just to have that kind of release valve, which could be a conversation with a colleague, either near or far, who is trying to push that same boulder down the hill.

Feeling alone is so hard. It takes a village and we all have to work together and figure out how we are supporting each other. And maybe that's something that those of you who are listening to this show can really keep in mind and think about how on somebody's worst day, stay if we are there and able to say, good on you, keep it up, you're amazing. 

That really matters. So maybe as our last piece of advice here, there's, it's a commitment to support each other and to keep our eyes open for those who are trying to do better, do right, fix something, to just offer them a measure of our heartfelt support and thanks and appreciation because that actually maybe make all the difference in the world.

[00:37:18] Dr. John Lee: Yeah, absolutely. And be able to have some sort of private mechanism to do that. Because a lot of times you're hesitant to do this in like a public forum. But if you have some degree of familiarity and trust with somebody who thinks along the same lines as you and being able to pick up the phone or text them.

[00:37:35] Stacey Richter: I think that that will go a long way. I couldn't agree more. I mean, there's plenty of times where I'm about ready to throw in the towel any day of the week and someone just comes out of the blue and says thank you or much appreciation or this was really meaningful to me. I can tell you just personally how much that really matters.

Concluding Thoughts and Call to Action

[00:37:52] Stacey Richter: Dr. John Lee, is there anything that you wanted to mention that you didn't have a chance to in the conversation today? 

[00:37:58] Dr. John Lee: Be happy in the small things. Have conviction in the things that you think you want to do is right, that it is right. Keep plugging away. It may not turn around all at once. You may not be that person who pushes that boulder down the hill.

But be happy that you may have contributed to taking one of those pebbles out. 

[00:38:16] Stacey Richter: Hear, hear. If someone's interested in learning more about your work, where would you direct them? 

[00:38:21] Dr. John Lee: LinkedIn. Probably the easiest place to connect with me. 

[00:38:24] Stacey Richter: Dr. John Lee, thank you so much for being on Relentless Health Value today.

[00:38:27] Dr. John Lee: Thank you. 

[00:38:28] Stacey Richter: Hey, if you are part of the Relentless Tribe working hard to transform healthcare in this country, I don't need to tell you that we need as many on our side as we can get. The most vital thing that you could do to help expand the reach of this show is to leave a rating or a review on iTunes or Spotify and or share this show with colleagues or decision makers.

Personally, I cannot appreciate it more when I see the reviews and they really count towards our search rankings. Thanks so much for listening.