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[00:00:00] Stacey Richter:

During the recording of episode 410, where Larry Bauer was explaining some really cool and innovative bright spots in the healthcare industry created by physicians. We somehow got off on a tangent about an article in JAMA from 2010, and I was all in.

Unfortunately, going all in on a topic that has nothing to do with the actual topic of the Currently in Progress podcast means one thing. And you probably know by now what that one thing is. Yep, summer short. So let me unveil for you our last summer short of 2023. 

Exploring the JAMA Article on Physicians

[00:01:01] Stacey Richter: Today we're going to talk about doctors and the societal perception of them as being a knight, a knave, or a pawn.

All of this is from a JAMA article that is entitled, surprisingly enough, Societal Perceptions of Physicians, Knights, Knaves, or Pawns. And it's by Dr. Sachin Jain and Dr. Christine Kassel and is unfortunately firewalled, but I will link to it anyway. To get us started here, this is the first sentence of that JAMA article.

The British economist Julian Legrand suggested that public policy is grounded in a conception of humans as knights, knaves, or pawns. Human beings are motivated by virtue, knights, or rigid self interest, knaves, or are passive victims of their circumstances. Pawns. And yeah, that plays out. 

Knights, Knaves, and Pawns: A Deeper Dive

[00:01:54] Stacey Richter: Why can't physicians own hospitals?

Well, in somebody's eyes, Doc's got a knave rap. How'd that happen? I don't know. I could make some guesses. Even if it's a small percentage of docs doing knave y money grabs or power hungry things, there is spillover. We societal humans, after all. Like, black and white, not gray. So everybody gets painted with the same brush in the same color and policy gets created to control the lowest common denominators.

The Impact of Perceptions on Healthcare Policy

[00:02:23] Stacey Richter: I love this conversation with Larry Bauer that follows because it explains a lot of sequelae, if you will, that I couldn't quite put my finger on the root cause of. So, in the brief but fast moving clip of the conversation that follows, Larry Bauer and I chat about docs as knaves or knights, but we don't get around to pawns, so I did just want to chuck in my two cents here about this third category.

I also will say that since I've got these three new classifications, I find myself using it to predict actions to some effect, I might add. Like I was chatting with someone recently and I said something about doing well by doing good, and he replied, well, how about this? You can do the good and I'll focus on doing well by doing well.

Okay, so that's a predictive layup. The harder ones are where people with a lot of press training and social capital do talks about doing good and being nightly, but then you listen to the minutes of their board meetings and wow, are they focused on revenue maximization at the expense of patients and their fellow doctors.

This happens. More often than I would like to see, but then again, I would like to see this happen never. As I mentioned about eight sentences ago, the category we don't talk about in this conversation with Larry Bauer that follows, which has also occupied a chunk of my mind space lately, are pawns. As with all of these categories, it's not just docs who fall into them, but everybody else too.

Pawns are super interesting. You might be way ahead of me here and have been thinking about this for years because on its face, this is obvious, but sometimes there's truth hiding in plain sight, so I'm not embarrassed to keep talking about this in case it helps you connect the same dots I've recently started to connect.

I will state at the outset here that those who I would chuck in the pawn category Do not listen to this podcast, neither do knaves. They do not like the show at all. The show forces a level of self reflection and awareness and to some degree accountability about the net net of some of the goings on that those who don't want to hear it don't like at all.

I was reading an article the other day about the Tragedy of organizational decision making, kind of like the tragedy of the commons if you're familiar with that terminology, but don't worry about it at all if you're not the tragedy of organizational decision making is that everybody in companies, especially big ones are making lots of decisions.

Tens of thousands of decisions happen in any given company on any given day. But so few then feel accountable or responsible or are even keeping track of the downstream and ultimate impact or consequences of any of the combined actions. It's this big machine and you'll hear some people say that they are but a cog just doing my job.

With no sight line into patient or member or community or societal impact, without this context or accountability or ownership, it is so easy to make decisions that take to the extremes what should be a nuanced plan of action, and then we get what we've currently got. Look, anybody who is part of a larger organization has to toe the party line, to some extent.

The Role of Accountability and Bias

[00:05:37] Stacey Richter: But there's a difference between making informed choices and seeking ways to deliver a net positive for those we ultimately serve, and doing things without contemplation. This is one thing that I love about the Relentless Tribe, just how much contemplation happens. I am still working this out in my own head.

I would welcome your feedback and thoughts. But from what I've seen so far, what pervades some of this pawn like thinking might be, and I empathize with this a lot, it could be a feeling of powerlessness. Like, why bother being a knight because nothing I do really matters anyway? Sometimes people just throw hands in air and you have familiar feeling, even amongst those of us who try to think things through and have manifestos, so I get it.

But whereas this feeling of powerlessness causes some of us, meaning you and me, to double down on reflection, it may cause others to just quit trying altogether because they think they have a snowball's chance in hell of influencing absolutely anything. 

Inspirational Thoughts and Quotes

[00:06:36] Stacey Richter: If it helps you in conversations that you might be having at some point with someone who may be feeling powerless, here's a quote I memorized.

Great things are done by a series of small things brought together. That was Vincent van Gogh who said that. You also have Malcolm Gladwell from his book Tipping Point, which talked about how many people have to be doing something to reach a tipping point. 12%. That's doable. If basically one out of ten ish people in any organization becomes a knight, the minority becomes the majority.

Or here's another quote that has some problems admittedly, but it makes a good point if you don't cognate on it too hard. If you think you are too small to make an impact, try going to bed with a mosquito in the room. That was Anita Raddick. Anyway, I hope that's inspirational or helpful to you in some way.

My name is Stacey Richter. This podcast is sponsored by Aventria Health Group. 

Interview with Larry Bauer

[00:07:31] Stacey Richter: And here is Larry Bauer. Larry Bauer, welcome to Summer Shorts. 

[00:07:35] Larry Bauer: It's great to be with you, Stacey. 

[00:07:37] Stacey Richter: So let's talk about physicians. Are they knaves or are they knights? And depending on what someone's view is on which one has a very big impact on how policy gets created, how processes get created.

It's so many different things. 

[00:07:55] Larry Bauer: I think the answer to the question, are they knaves or are they knights, is a fundamental one which will determine the path that you take in terms of how you interact with them. For example, if you think that physicians, in particular, are knights, then you recognize that they got into it for the most part because of their interest in helping people.

They want to be part of what I call the healing community that makes a difference in terms of people's lives. If you see them as knaves, then you'll go down a different path because you look at them as people who are just in it for the money. And they are trying to maximize the money or the power for themselves and really manipulating and can't be trusted.

So it's a fundamental bifurcation, if you like, of your philosophy about physicians and doctoring. 

[00:08:56] Stacey Richter: Yeah, I think it's also a really fundamental genesis of how lots of things go in very different directions. You know, like I often hear how physicians can't own hospitals because Given their clinical knowledge, they are so able to cherry pick with such great technical skill that things can go completely awry in the revenue maximization direction.

Or prior auths, for example, which, and there's a whole lot that's baked into that, but we got to have all these, these arduous prior auth processes. Why? Because we can't trust doctors. Right. Let me ask you this. In your storied career, you've been doing this a long time. If you had to, I mean, what are we looking at, a bell curve?

Like, because you certainly can't say that everybody's a knight or everybody's a knave. So is this a normal distribution curve or like, how are you assessing this? 

[00:09:55] Larry Bauer: In my experience, and I've been at this with doctors and I'm a social worker, I've been working with them for 40 plus years. Most of the people, almost all of the people that I meet, I would actually put under the cap of knights.

I have met some who are into wealth production as a goal, and I've met some who are into power as a goal, and defending their turf. But by and large, the healing community is quite ubiquitous, and I really think it comes down to the attitude, the, the viewer. Whether it's an administrator or a policy person or a legislator, the view that they have, accountability is obviously important, but more important than accountability is commitment through a philosophy of care towards a healing mission. So it's important for all of us to be aware of our own biases in this regard. 

[00:10:56] Stacey Richter: Yeah, and for sure, everyone is influenced by the incentives that are out there and anyone who overlooks that is gonna have a problem. We all need to be self aware that if we're getting paid more to do one thing, we have a tendency to do that. thing. And this can get dicey really fast because as per studies by Dr. Aaron Mitchell and colleagues listen to that episode, almost any payment, direct or indirect, turns out skews physician decision making, period. And as I heard on some conman documentary somewhere, anybody who thinks they are above the realities of being human is the easiest mark of all.

So, if a policymaker or an administrator believes that most docs are knights, How does one use that as empowering? Like, if I think doctors are knights, how do I catalyze then their ability to do even more good?

[00:11:52] Larry Bauer: I think the first thing you do is you go ask them their opinion. I was in a meeting. It was a health care coalition, but it was the employers getting together to figure out how they were going to address the expense of health care.

That they were being called to underwrite for their employees. And when I went into the room and I learned who was there and what they were up to, they were coming up with a program that was going to quote, incentivize docs to do the right thing. And they had a whole series of measures that they had created.

And I was fascinated when I learned who was in the room, there wasn't a physician in the room. They were all. People who worked for the employers, they were advocacy organizations, everybody but the doctors. And I get that it's hard when doctors, particularly the primary care community, they, they have to see patients every day in order to generate the financial flow to keep their practice alive.

All these administrators, what they do is go to meetings. That's how they generate their livelihood, so to speak. But they weren't asking the docs. They were thinking they understood how you could really manipulate the docs to get the outcomes that they wanted. And the program that they created didn't succeed, and in large measure, I think it's because they didn't start working with the docs.

I think there have been some good examples now where the employer community has learned from that mistake, and they're now doing a better job. The Pacific Business Group on Health, for example, has done a wonderful job of partnering with the docs to talk about health outcomes and what it would take.

Especially at the primary care level to deliver the positive outcomes that they wanted. But that's a fundamental issue. 

[00:13:42] Stacey Richter: It's something that maybe we should surface here. If you feel like you need to, in quotes, manipulate physicians to do the right thing, you think physicians are knaves. Yep. And that I think is a really important to keep in mind as we think about what our own biases actually are and the place that we are coming from. Because we talk about moral injury in this country. We talk about burnout in this country. And if every single day you're someone who went into medicine or the business of medicine because you want to do right by patients and you are being treated like you are going to screw everybody like that could be a very punitive environment.

[00:14:24] Larry Bauer: Oh, absolutely. And it's very palpable. It's not like it's an abstract problem. It's very, it's built into our lack of a coordinated healthcare system. 

[00:14:34] Stacey Richter: So again, just going back to a really fundamental question that probably anybody in an administrative role in a policymaking role in a. Purchasing role probably should sit down and contemplate and get real with themselves is what is the view of physicians or the medical community?

Like what are individuals trying to do and accomplish? And just again, state the obvious here. We cannot. Assume that a provider organization or a hospital is a homogeneous blob. In other words, we have consider that there's an interview with Dr. Sue S. Gandhi. They did a study. They found that on hospital boards, a lot of people have a private equity background, right?

Like there's. single digit percentages of doctors and less than 1 percent on boards who, who have a resume that includes nursing. So you have administration of hospitals that are not representative a lot of times of the people that work there. And then certainly you have hospitals across the country that are quite different than other hospitals, just in terms of their behavior and what they're doing.

So certainly not suggesting that the principles and the personal integrity of an individual physician is a lot of times represented by the organizations that they serve for and what that organization might be willing to do. 

[00:16:02] Larry Bauer: Stacey, let me tell you a quick story. I was in my younger days, a very active playing basketball and I had a basketball team that was composed of physicians. I had a gastroenterologist. I had a couple family physicians. I had a cardiologist. I had an orthopedic surgeon. We all love playing basketball. We also had hospital administrators on our team. There were about 12 of us and we played in a league on a weekly basis. And after the game, we would typically go out and have a beer together and have a wonderful fellowship experience.

So this one particular evening after the game, we were doing the same as I mentioned. And for some reason, all the physicians left first, which left the hospital administrators. And the hospital administrators thought of me as one of them because I'm not a physician. And I guess they thought I was a little bit more approachable or something.

At any rate, as soon as the physicians left. The doctor joke started and the doctor jokes basically are doctors are, they're lousy interpersonal skills, they're lousy at business, and it really, when you listen to them, they're pretty derogatory. And I wondered to myself, this has never happened before.

There's never been a doctor joke while one of the doctors was sitting at the table drinking the beer with us. And, and I wondered about that and what I realized is that the hospital administrators were intimidated, afraid of the physicians. And that crystallized for me a whole lot of the behavior. When you're talking at the board level and there are no physicians or nurses at that level, it is absolutely crazy in my opinion.

In a service industry where you don't have the people and forget not having patients on the board, you don't have patients or the clinicians, the people around whom all of the services of the organization rotate and all the revenue flows. To not have them represented in this decision making level is a real blunder, in my opinion.

[00:18:09] Stacey Richter: As Dr. Matt Anderson said on this podcast, and this was years ago now, but it's still really relevant. Is it the suits versus the scrubs? Yeah. Like the fact that there's such misalignment there and different groups are making jokes about the other one when they're all supposed to be on the same team, is...

Again, these are underlying issues that much bad springs from. 

[00:18:35] Larry Bauer: Yes. And by the way, it's not only the suits and the scrubs, it's the suits, the scrubs, and then the community of physicians in the larger community who are totally outside of the organization, but on whom that organization depends for referrals and services.

[00:18:52] Stacey Richter: Yep. We have a larger flowchart here. Do you have any final words on this topic? 

Final Thoughts and Recommendations

[00:18:57] Larry Bauer: I guess my final word would be, and this is going to the physicians, particularly the primary care physicians, I have been advocating for many years now, it would be very advantageous to invite a local policymaker, a local politician, legislator into your practice for a half day.

So they can see what you're doing. The doctor shows on TV don't represent very well. In fact, some of them are absolutely crazy for representing what actually goes on. So people's idea of what takes place in the ER or the OR or a physician's office in the community is very poorly understood. Invite people to come in, spend a half day, and let them learn firsthand what you're doing.

People will walk, whenever this happens, and I have been able to facilitate this a few times, whenever this happens, people walk away incredibly impressed by what they learn.

[00:20:01] Stacey Richter: So in sum, ask doctors. Get them on the committee, number one, and then number two, get policymakers into clinics so that they can get closer to the ground.

Larry Bauer, thank you so much for being on this summer short today. 

[00:20:17] Larry Bauer: It's my pleasure. Thank you very much for asking me, Stacey.