EP438: Recognizing Cognitive Dissonance and Thinking About How to Overcome It When in the Belly of the Beast, With John Lee, MD

[00:00:00] Episode 438, recognizing cognitive dissonance and thinking about how to overcome it when

[00:00:09] in the belly of the beast.

[00:00:11] Today I speak with Dr. John Lee.

[00:00:22] American healthcare entrepreneurs and executives you want to know, talking, relentlessly seeking

[00:00:29] value.

[00:00:30] Cognitive dissonance is kind of rampant in the healthcare industry.

[00:00:34] Cognitive dissonance is when what someone winds up doing, their actions are in conflict

[00:00:40] with what they believe in.

[00:00:41] Cognitive dissonance also can mean when someone holds two contradictory beliefs at the same

[00:00:47] time.

[00:00:48] Like, let's say a person believes they want to do well by patients, but their performance

[00:00:53] review depends on, as just one example, making care less affordable for patients.

[00:00:58] But somehow this individual is able to conclude that what they're doing is a net neutral or

[00:01:03] a net positive, despite, in this hypothetical, let's just say obvious indications that it

[00:01:08] is not.

[00:01:09] In this hypothetical, there are, say, clear facts that show that what this person is up

[00:01:14] to is indisputably a problem for patients.

[00:01:17] But yet at every opportunity, this person talks about their commitment to patients.

[00:01:21] This rationalization or earmuffs don't look, don't see is cognitive dissonance.

[00:01:26] Now, it's harder to engage in cognitive dissonance the closer you are to patients because you

[00:01:32] see the impact up close.

[00:01:34] This is probably why moral injury and burnout is most associated with clinicians who are

[00:01:40] seeing patients.

[00:01:41] Unless these at-the-bedside clinicians enjoy a robust lack of self-awareness, those who

[00:01:47] are seeing patients don't a lot of times have the luxury of pretending that what is going

[00:01:52] on is good for patients when they can see with their own two eyes that it is not good for

[00:01:56] patients.

[00:01:57] The further from the exam room or the community, however, the easier it is to not acknowledge

[00:02:03] the downstream impact.

[00:02:05] If you can even figure out what that downstream impact is, which is also worthy of being mentioned

[00:02:10] when the machine is really big, sometimes it's legitimately difficult to connect the

[00:02:15] dots all the way down the line to the customers, members or patients.

[00:02:19] Kate Wollen talked about this in an episode a couple of weeks ago.

[00:02:22] But this whole dissonance exploration was a big reason why actually I created my manifesto,

[00:02:27] which is episode 400, because almost everything that we do in health care wherein we are making

[00:02:33] money or helping someone else make money is dissonant to some degree.

[00:02:37] And it literally keeps me up at night contemplating how much dissonance is too much dissonance

[00:02:42] or how much self-interest is too much self-interest.

[00:02:45] This is tough, subjective stuff.

[00:02:48] So again, episode 400 for more on at least how I think about this.

[00:02:52] But today I am talking with Dr. John Lee about what to do in the face of all this when

[00:02:58] working in the as I call it, the belly of the beast, working for a large health care

[00:03:03] organization such as a hospital, because hospitals sometimes and we certainly do not want to

[00:03:08] put all hospitals in the same category.

[00:03:10] They are a wildly diverse bunch.

[00:03:12] But sometimes some people at some hospitals do some things which are not things I think

[00:03:18] they should be doing anyway.

[00:03:19] They're fairly egregious breaches of trust, actually.

[00:03:22] But yet within that same organization, you have doctors and other clinicians or others

[00:03:27] who are working really hard to serve patients as best they can.

[00:03:31] This is the real world that we're talking about.

[00:03:33] And the question of the day is, so now what?

[00:03:37] While it would be amazing if someday we build a whole new health system that didn't include

[00:03:42] some people doing things that I don't think they should be doing, that day is not today

[00:03:47] and it's not tomorrow.

[00:03:48] I'm going to hope that there's other people in our village who are full on doing the

[00:03:53] disruption thing.

[00:03:54] But if we are not able to do that personally for whatever reason, but we still want to

[00:03:59] inch forward within the existing environment and do the things that make us feel like we're

[00:04:04] achieving our mission.

[00:04:06] What's the best way to think about this?

[00:04:09] That is what I asked Dr. John Lee.

[00:04:11] And that's what our conversation is about today.

[00:04:14] Summing up his advice, which is really good advice.

[00:04:16] Dr. Lee talks at length about how it's so important to celebrate the small wins and feel

[00:04:21] good about care that is a little bit better than it was six months ago.

[00:04:25] He talks about acknowledging that you can't do everything.

[00:04:29] He talks about incremental improvement that helps both patients, but also colleagues.

[00:04:34] And that's not insignificant to really consciously consider how to work together and help to

[00:04:39] support each other.

[00:04:41] Look, I just finished reading a post on LinkedIn about toxic medical culture and just how

[00:04:46] brutal and cruel some physicians and physician leaders and others can be to their

[00:04:51] colleagues. Anne Richardson writes about topics like this a lot.

[00:04:55] Follow her on LinkedIn if you're interested.

[00:04:57] So does J.

[00:04:58] Michael Connors.

[00:04:59] But just saying it's pretty cognitively dissonant to talk about, like the potential of

[00:05:04] team-based care and then condone or engage in toxic behavior with those same team

[00:05:10] members. There's like 90 studies on this whole topic linked to a book in the show notes.

[00:05:14] But bottom line, fixing cognitively dissonant paradigms in any sort of durable or

[00:05:20] scalable way is for sure going to require a culture that inspires constructive criticism,

[00:05:26] innovation and collaboration.

[00:05:28] It also requires and this is Dr.

[00:05:30] Lee's last piece of advice.

[00:05:31] It's really important to seek out like minded individuals as sounding boards and as a

[00:05:36] support network to commit to supporting each other.

[00:05:40] And I hope all of you that you feel like you found your tribe here at Relentless Health

[00:05:45] Value. You guys are an amazing bunch.

[00:05:48] So know that and don't hesitate to reach out to each other when you need help.

[00:05:52] And I know, I know I need to create a directory so you can all hook up more easily.

[00:05:58] So do subscribe to the weekly email because I am inching closer to finally managing to

[00:06:03] get this done. And you won't know about it unless you're subscribed.

[00:06:06] Go to the website, RelentlessHealthValue.com.

[00:06:09] You will be hit with a pop up window fast enough.

[00:06:12] But back to easing cognitive dissonance and the why here.

[00:06:16] I thought Michelle Burnaby put how much of a difference the right culture can make for

[00:06:21] patients and those who work together really eloquently recently.

[00:06:24] This is a great why, since we spend so much of our life at work.

[00:06:27] She wrote each day we come together ready to roll up our sleeves, committed to our own

[00:06:31] growth, our boundaries and our teamwork.

[00:06:33] This collective dedication resonates throughout our organization and is, I trust, felt by

[00:06:39] our clients and our partners.

[00:06:40] In the conversation that follows, Dr.

[00:06:41] John Lee offers a really nice array of examples of incremental in the belly of the beast

[00:06:46] stuff that might be possible in the real world, at least in the bellies of some beasts,

[00:06:51] plus some other points of contemplation.

[00:06:53] Dr. Lee is an ER doc, emergency room doc by training, who is also an informaticist and

[00:06:59] chief medical information officer.

[00:07:01] I can tell you from personal experience that Dr.

[00:07:04] Lee is one of the most creative and pragmatic problem solvers that I have encountered.

[00:07:08] He says he's dedicated to trying to help move the ball forward and changing our

[00:07:12] healthcare system using information technology and using our ability to be far more

[00:07:16] transparent with the things that we try to do in a positive way in health care.

[00:07:20] So without further ado, my name is Stacey Richter and this podcast is sponsored by

[00:07:25] Aventria Health Group.

[00:07:26] Dr.

[00:07:27] John Lee, welcome to Relentless Health Value.

[00:07:29] Thank you so much for having me.

[00:07:30] This is the highlight of my day.

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

[00:07:35] Why don't we just start out with if you're thinking about cognitive dissonance, how do

[00:07:40] you think about it?

[00:07:41] What is it relative to the health care industry?

[00:07:43] There's a lot of rhetoric saying we have to change how we do things.

[00:07:48] Once people who buy into that get into the system and try to change the system,

[00:07:54] particularly from the inside, they're often overwhelmed by the tide of the momentum

[00:07:59] continuing to push the system in essentially in the same way that it has been

[00:08:04] continuing to go for the past several decades.

[00:08:07] The cognitive dissonance that you're describing is the feeling that I wish we could

[00:08:12] do more, but the system just won't let us.

[00:08:15] And there's many people who've talked a lot about this.

[00:08:18] But just from a personal perspective, it's sometimes can be very frustrating.

[00:08:22] And one of the reasons why I gravitated toward your podcast because it was a different

[00:08:27] tribe that I could feel like I could belong to, that at least maybe I can't make that

[00:08:32] sort of grand scale impact that I want to make.

[00:08:35] But at least I can be surrounded by other people who are of a like mind.

[00:08:40] Well, I appreciate that.

[00:08:41] And that is actually a goal of the podcast to provide a sort of community that can wrap

[00:08:47] around and give some bolstering and comfort to those who may feel very alone for maybe

[00:08:54] the reasons that we can talk about right now.

[00:08:57] You have a system that after all this time, very fee for service oriented.

[00:09:02] What are the incentives that start to wind up bearing down on individuals who are

[00:09:09] operating in the system as a clinician or as someone who is working directly with

[00:09:14] patients?

[00:09:14] There was this one presentation given by an internal medicine physician, and he and his

[00:09:19] team stood up a really, really good heart failure program.

[00:09:23] High touch, lots of people making phone calls, touching base with really sick, chronically

[00:09:27] ill heart failure patients.

[00:09:29] And they were really successful.

[00:09:31] They were really successful in reducing the number of hospitalizations that these heart

[00:09:35] failure patients were having by almost like a third or half or something like that.

[00:09:41] And it was a fantastic presentation.

[00:09:43] I went up to him afterward, congratulated him, shook his hand.

[00:09:46] And his comment afterward was, yeah, I didn't want to say it during the conversation.

[00:09:50] He looked a little bit downcast.

[00:09:51] And he said, yeah, we have to actually sunset this program because it is too successful.

[00:09:57] Well, first of all, number one, it's very resource intensive.

[00:10:00] So it costs a lot of money.

[00:10:02] But the commentary that he made was that my CEO told me that we have to stop the program

[00:10:08] because it's reducing heart failure admissions too much.

[00:10:11] It's costing the hospital money.

[00:10:13] And actually, I just recently listened to your podcast with Scott Conard who talked

[00:10:19] about how in a similar way, in a larger sense, his clinics were so, so successful that the

[00:10:25] health care system bought his clinic and then shut it down because they were reducing the

[00:10:30] number of hospitalizations.

[00:10:32] That's the sort of cognitive dissonance that is so frustrating to people who want to try

[00:10:36] to actually improve our system.

[00:10:39] Paraphrasing what you said there.

[00:10:40] So here you are and here the doctor who set up that heart failure program was.

[00:10:47] Here's Dr. Scott Conard.

[00:10:48] There are so many examples of great clinicians and very mission driven individuals across

[00:10:53] the country.

[00:10:55] Jodelyn Owen is another one with Maternal Health.

[00:10:59] Rob Andrews also talks about this on the show, wherein the way that the money flows right

[00:11:04] now, you don't get paid a lot for preventing anything.

[00:11:08] Despite all the hoopla about value based care, 1% of heart failure patients are on optimal

[00:11:15] medical therapy in this country.

[00:11:17] I can cite stats like that off the top of my head because I was so shocked.

[00:11:20] Not only do we not have chronic disease patients who are being treated in ways that have been

[00:11:27] demonstrated to work, but then we have a system that is actively kneecapping anybody that's

[00:11:33] trying to do that.

[00:11:34] The money doesn't work.

[00:11:36] Yeah. And I would say that the sorts of conversations that I had with that internal

[00:11:41] medical physician is probably more an exception rather than the rule.

[00:11:45] Most healthcare systems are just obliviously ambivalent and satisfied with doing things

[00:11:53] the current way that they're doing it.

[00:11:55] And the technology that then they apply then is applied to basically maintaining the current

[00:12:01] status quo, but just doing it faster or doing it more efficiently.

[00:12:04] Well, it's interesting because I also was at a physician summit a couple of years ago

[00:12:09] and I listened to a doc who also stood up a heart failure program to prevent readmissions.

[00:12:14] And it was also very successful and it also got shut down.

[00:12:19] And I think the reason given was that too many readmissions were being avoided and there

[00:12:25] was more money in those readmissions than in the paltry CMS fines.

[00:12:30] Actually, you know, the show with Dr.

[00:12:31] Rishi Wadhira gets into this in depth.

[00:12:34] And yeah, he cites a whole study that also bears this out.

[00:12:37] So for sure, you definitely have system level factors that start pressing down on

[00:12:42] individuals. But so I know of many of my colleagues who are very focused on RVUs and

[00:12:51] the volume of services that they produced.

[00:12:54] But I also know that they're really good docs who really, really care about their

[00:12:58] patients. But they're existing within an environment that just induces that sort of

[00:13:04] behavior so that it's less of an issue where they're trying to, they're not trying to

[00:13:09] game the system, but the system has almost gamed them.

[00:13:13] And you can't really blame most of the people for doing the things the way that

[00:13:19] they're doing them. And what we have to do is try to actually change the system.

[00:13:23] But a third of health care waste is somebody else's profit.

[00:13:26] That profit buys a lot of influence.

[00:13:29] Let's talk about how these systemic pressures really press down on individuals.

[00:13:34] You know, there is an epidemic of burnout in this country.

[00:13:39] As I've heard it said, burnout is moral injury and a cheap Halloween costume.

[00:13:44] Maybe moral injury is another word for cognitive dissonance, right?

[00:13:47] It's just what happens when personal values and personal missions collide with these

[00:13:54] systemic level pressures.

[00:13:56] So if I'm just making a list of things that create this cognitive dissonance, it's the

[00:14:02] way the comp models work.

[00:14:03] You mentioned RVUs.

[00:14:05] Yeah, you know, let me kind of paint a picture of something that has been a theme,

[00:14:11] particularly among some of my ambulatory and primary care based colleagues.

[00:14:15] They are constantly being pushed harder and harder to see more and more patients to

[00:14:21] increase that volume based revenue.

[00:14:23] And at the same time, they have all these sorts of quality based check marks that they

[00:14:29] are required to fulfill as they work harder and harder and faster and faster.

[00:14:35] Before, instead of seeing 25 patients in a day, the organization was okay having them

[00:14:40] see 20 patients in a day.

[00:14:42] And it may have been still fee for service.

[00:14:45] They still had some wiggle room to talk to the patient about other stuff and connect

[00:14:50] with the patient so that that sort of interaction assuaged some of that moral injury

[00:14:55] that was occurring.

[00:14:56] Now, you're squeezing all that stuff out and it all just becomes like you're a CPT

[00:15:01] RVU machine.

[00:15:03] That's where a lot of the burnout comes from.

[00:15:05] And I think from a technology perspective, there is the ability to actually change that

[00:15:10] paradigm, to introduce more team based care, to actually create very proactive

[00:15:16] mechanisms so that the primary physician who's responsible for a particular patient may

[00:15:21] not necessarily have to spend a ton of time with that patient because he has an entire

[00:15:24] team surrounding him to support how that physician interacts with that patient.

[00:15:29] So that if they do have that interaction with the patient, they actually feel like

[00:15:33] they're actually moving the ball forward and improving that patient's life or I guess

[00:15:37] to use the Peter Atiyah term, improve that patient's health span.

[00:15:41] To underscore that point, my mother made an appointment with her doctor.

[00:15:46] When she was on the phone making the appointment, she was told you're not allowed

[00:15:52] to bring up anything else but your chief complaint while you're in the room seeing the

[00:15:56] doctor.

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

[00:16:03] injury. We are people.

[00:16:05] We want to interact and feel like we're connecting with the people that we're serving.

[00:16:09] The way that the system has developed and quote unquote matured over the past few years

[00:16:14] has really taken that away from us.

[00:16:16] And just to state the obvious here, another word for connects with people is to build a

[00:16:22] relationship that has trust with people.

[00:16:25] So there's obviously consequences on both sides of the room there in which you have a

[00:16:31] physician who is being treated or feels like an RVU machine, a CPT code machine, as you

[00:16:38] just said. But on the other side, you've got a patient who's like, I guess I'm a widget

[00:16:42] too.

[00:16:43] So we have a system at this juncture that is pressing people into these modes that

[00:16:50] reduce the human aspect of health care.

[00:16:54] If I'm reinterpreting what you just said, layer onto that the idea which could be

[00:16:59] especially demoralizing to someone such as yourself who can see a way forward, who can

[00:17:05] see, wow, we could use technology in this way.

[00:17:08] We could do this. We could do that.

[00:17:09] There's so many ways that I could see to improve this.

[00:17:12] And then you have a system that's like, nah, I think not.

[00:17:15] Right. Like I could also see how that would be frustrating to the good people, you know,

[00:17:20] like the people that wanted to try to figure out how to fix it and no one is interested.

[00:17:26] And one of the things that I've sort of migrated to in my thinking is that I'm not

[00:17:31] going to make that wholesale massive change.

[00:17:34] What I can do is nibble around the edges, help things in little ways.

[00:17:39] And even if I get just a little win, hopefully I will be that one little win

[00:17:44] compounded with other little wins that other people make as we try to improve our

[00:17:49] health care system.

[00:17:49] It's interesting how you put that because in the show with Barbara Waksman, she was

[00:17:54] advising those who wished to sell something to employers to not nibble around the

[00:17:58] edges, but to do something big enough to get an employer's attention.

[00:18:02] I know some of you are thinking about that right now.

[00:18:04] And I'd say that both of these things can be true simultaneously because Dr.

[00:18:09] Lee, what you're talking about is working from within the belly of the beast,

[00:18:14] surrounded on all sides by giant institutions.

[00:18:17] So for you, the best path forward might be small things that make a difference right

[00:18:22] now for patients and your colleagues.

[00:18:24] And I feel like I'd be remiss not to mention that this is a very different use case

[00:18:30] than what Barbara Waksman was talking about.

[00:18:32] What works in some situations as we think about bigger and more disruptive is just

[00:18:38] not going to work for somebody else.

[00:18:39] It's just not even possible.

[00:18:41] Both are kind of solving different problems at different timeframes.

[00:18:45] And it's these kinds of differences, which is the background why I put together the

[00:18:50] manifesto that I did, which is episode 400.

[00:18:54] And I've gotten innumerable messages and calls from individuals who said, you know,

[00:18:58] thank you for helping me put into words what I really feel here.

[00:19:03] So what I want to hear from you is, OK, you know, now what?

[00:19:07] How do you make lemonade out of lemons?

[00:19:10] How do you contemplate still feeling like you're working in alignment with your

[00:19:14] values and what you want to accomplish despite so many pressures?

[00:19:19] You and I have had some conversations earlier where if you come up with something

[00:19:23] that you'd like to do and then there's all sorts of obstacles in the way, you said

[00:19:28] it's really easy to become disillusioned.

[00:19:30] And you were talking about how your advice and your mindset then has to be, OK, in

[00:19:35] the face of what's going on, what can I do?

[00:19:37] What can I accomplish?

[00:19:39] So how do you think about the incremental improvements that you can realistically

[00:19:45] make or what are some examples of things that you have done?

[00:19:49] One of the things that I'm really, really proud about is I helped create a system that

[00:19:53] my fellow emergency physicians, they were actually OK with it.

[00:19:57] Unlike many other colleagues around the country, they viewed the system as pretty well

[00:20:02] designed. And so that for me was that one little thing moving the ball forward so that

[00:20:08] we could actually start digitizing some of the data that our system creates in taking

[00:20:13] care of patients. And in me helping my colleagues be more comfortable with a digital

[00:20:18] system, now we've created data.

[00:20:20] That data can then inform other tools downstream that can help transform the system.

[00:20:26] That's the very first step.

[00:20:27] We can't do anything else without doing that.

[00:20:29] And then another is just coming up with different ideas.

[00:20:32] Some of them may not stick.

[00:20:34] So your podcast with Kenny Cole, within it he mentioned something about metformin and

[00:20:39] how people stop taking metformin because of gastrointestinal side effects.

[00:20:44] But I know that how that's documented within the system, it's very different based on

[00:20:50] who documents it and what system they document it in.

[00:20:53] If we could somehow encapsulate that as a piece of data that's consistent and reliable

[00:20:58] across systems or across offices or across practitioners, then you can start aggregating

[00:21:03] that and then being able to say, OK, these are the things that actually predispose

[00:21:09] somebody who is on metformin to stop taking it because of gastrointestinal side effects.

[00:21:14] And then if you can start encapsulating that as a digital picture, then you can actually

[00:21:19] start putting into place even something simple as, well, we see based on the data that's

[00:21:26] in your system that you're predisposed to having gastrointestinal side effects.

[00:21:29] We are going to have somebody call you a week after you start metformin and see how

[00:21:33] you're doing and see if we can put in some mitigating processes so that you can stay

[00:21:38] on metformin. But the first step of that is actually encapsulating that as data.

[00:21:43] And what I did was I took that podcast, I forwarded it on to some people I knew who

[00:21:47] are very astute data scientists and they have a way to actually encapsulate that and

[00:21:54] encode that into something that is very easily digestible by multiple systems across

[00:22:00] multiple organizations.

[00:22:01] And that's something that would be really valuable.

[00:22:03] Now, I'm realistic enough to know that putting that out there and kicking that off

[00:22:08] may or may not go anywhere.

[00:22:09] But I keep trying because that's my makeup.

[00:22:13] I want to try to help move the ball forward and use technology to actually improve our

[00:22:18] health care system. And that's the sort of thing that I keep trying to do.

[00:22:21] I'm very inspired by you and the initiative that you have when you do stuff like this.

[00:22:26] It's another thing, but it also might be exactly what is necessary to feel like a

[00:22:31] difference is being made when you consider how you may help your colleagues.

[00:22:35] Like, how do I within my current role potentially support colleagues who are trying

[00:22:40] to figure out how to do right by patients?

[00:22:43] Which many are.

[00:22:44] And you give two examples there.

[00:22:45] One is in your role at the time and everybody's going to have their own example of

[00:22:50] this. But you were tasked with building an ER IT infrastructure, the system that you

[00:22:56] built aligned with what your colleagues needs are, not just what somebody dictated from

[00:23:02] above. So you took the time to ensure that the system that you built was going to work

[00:23:05] for colleagues as well as the hospital system writ large, which I can definitely see

[00:23:11] would give a measure of appreciation and pride, rightfully so.

[00:23:16] And then the second part of this is what do patients really need?

[00:23:20] You gave the example of the episode with Dr.

[00:23:22] Kenny Cole from a couple of weeks ago.

[00:23:24] He talks about just how many patients fail on metformin because they're actually not

[00:23:29] taking it properly.

[00:23:31] I'm going to come off as a Stacey Richter fanboy on this, but I'm going to quote

[00:23:35] another episode that you had.

[00:23:37] I forgot what the exact quote was.

[00:23:38] You used a Marcus Aurelius quote, something about being happy with the smallest

[00:23:43] progress. And I think that's what we have to do.

[00:23:45] Some of us are big names, have big influence, have big personalities and can do big

[00:23:50] things, Mark Cuban-ish type things.

[00:23:53] But others of us, we have to be able to be satisfied with doing the right things that

[00:23:58] we feel like we can do and be satisfied with that.

[00:24:01] Figure out how to support your colleagues.

[00:24:03] You can figure out how to support patients in whatever ways.

[00:24:06] What's your advice for someone who might not have the same job as you?

[00:24:10] One of the teams that I used to work with, I would use this metaphor a lot.

[00:24:14] Our health care system, the dysfunction in our health care system is like this enormous

[00:24:17] boulder stuck on the side of a mountain.

[00:24:20] Just one person isn't going to push that boulder down the hill, which is what we need

[00:24:24] to do. But what we can do is take the little pieces of pebbles around that boulder.

[00:24:30] If enough of us are taking out enough of those pebbles, at some point that boulder is

[00:24:35] going to start rocking. And then once that boulder starts rocking, at some point

[00:24:38] somebody is going to be able to push it.

[00:24:40] And then once that boulder starts rolling, it can't be stopped.

[00:24:45] Because the things that we need to do with our health care system all make a ton of

[00:24:49] sense. Once that logic takes hold and the things that our patients need align with

[00:24:55] how we actually deliver health care, then it's going to be a force that can't be

[00:24:59] stopped. I may be being a little bit too optimistic, but that's what I truly firmly

[00:25:03] believe.

[00:25:04] That's a wonderful way to put this exactly like you just said.

[00:25:08] If there's a boulder and we each just take a pebble, then we can really create change

[00:25:14] in an organic way, even if it's not necessarily some kind of formal,

[00:25:20] collaborational alignment.

[00:25:22] That if each of us just thinks, what can we do?

[00:25:26] What are the simple opportunities?

[00:25:28] I think you've called it wherein we could make even a small difference if there's

[00:25:32] enough people who are thinking that way.

[00:25:34] Inevitably, change will wind up happening just because it's almost creating a zeitgeist

[00:25:39] of a certain kind.

[00:25:40] Yeah, absolutely.

[00:25:42] And you know...

[00:25:42] Great way to put it.

[00:25:43] The other thing, here's another word for a zeitgeist, a tipping point.

[00:25:46] One of the things in that Malcolm Gladwell book, if only 12% of individuals are

[00:25:52] pushing in a certain direction, tipping points happen.

[00:25:55] It's just it's amazing how word travels, ideas spread, especially if there's enough

[00:26:02] people who believe something in their heart of hearts and want to see something

[00:26:05] happen.

[00:26:06] And I do feel like there's so many across the health care industry that realize

[00:26:10] something's got to give.

[00:26:11] We just need to be able to push back against that system.

[00:26:14] And, you know, to use another metaphor, if the current system is a big river pushing

[00:26:20] us downstream, as difficult as it sounds, we need to reroute that river so it points

[00:26:25] in a different direction.

[00:26:26] So one of the things that you said was, as we just talked about, Dr.

[00:26:30] Kenny Cole talked about just how many patients stop taking metformin because of

[00:26:35] avoidable gastrointestinal symptoms.

[00:26:38] And that is something that could be codified if we A, know it because we have the

[00:26:43] data, but B, we can build something to disseminate that information.

[00:26:48] But what else?

[00:26:48] Give us some bright spots here, things that people may contemplate.

[00:26:51] So let's say you're a medical assistant in an office and you see the doctor doing

[00:26:57] all this labor that you think that you could do.

[00:27:00] Then maybe suggest, hey, maybe we can do this and take the load off your shoulders,

[00:27:05] doctor or to the nurse and feel like you're contributing more.

[00:27:09] It could probably positively impact how you feel about your being part of the team

[00:27:14] and contributing to the patient's care.

[00:27:16] Also making the team more effective and efficient.

[00:27:19] The other thing is to start identifying places where there are waste and they're all

[00:27:25] over the place.

[00:27:26] That sort of identification and the reporting and trying to execute on that sort of

[00:27:31] observation, that's an entire project altogether.

[00:27:34] But at least start maybe taking that and injecting kind of that culture of, you know,

[00:27:39] we shouldn't be really doing this or there is a different way of approaching this.

[00:27:44] Why is that printer way over there, 20 feet away from the computer when everybody goes

[00:27:49] to that printer for every single patient as we print stuff out?

[00:27:53] Little things can add up to a lot.

[00:27:55] Those are some great examples that have just so much packed into them.

[00:27:59] One of them is just make a suggestion.

[00:28:03] And it's in a way a commentary on the health care system today that even comes up.

[00:28:09] We've gotten ourselves into a place where we talk about team based care, but we have to

[00:28:16] bring up if someone sees something that could be improved, maybe we should talk amongst

[00:28:21] ourselves.

[00:28:22] Yeah, the unfortunate reality is that there's a lot of health care systems, maybe even most

[00:28:27] of them that are very hierarchical.

[00:28:29] The doctor or the C-suite administrator says we have to do it this way and people have

[00:28:35] to kind of march in line.

[00:28:37] I think it would benefit our health care system at large if we weren't like that as much,

[00:28:42] that if we could actually incorporate the sorts of suggestions or input of the entire

[00:28:48] team.

[00:28:49] And this is almost an organizational extension of the concept of team based care around a

[00:28:54] particular patient, but team based care from an organizational perspective.

[00:28:59] I just wish that a lot of our health care systems would absolve themselves of the top

[00:29:04] down hierarchical approach to managing.

[00:29:07] Well, here comes Gen Z.

[00:29:09] And the one thing I've heard about Gen Z is they really don't like hierarchy very much.

[00:29:13] But in a way, a command and control environment is somewhat antithetical to team based care.

[00:29:20] Having teams wherein the team feels afraid to speak up and make suggestions because the

[00:29:27] hierarchical, you know, like those that sit above them are going to lash out.

[00:29:31] Like there's a lot of consequences.

[00:29:34] It's in their best interest to promote that sort of stuff.

[00:29:38] So maybe contemplate what's the environment?

[00:29:41] Is there any influence that you might have on the environment that could enable people

[00:29:46] who are trying to do things in a better way or may have insight into how to improve?

[00:29:51] Can they feel like they can speak up?

[00:29:54] That's number one.

[00:29:55] Or number two, if you see something, maybe say something.

[00:29:59] And I'm not sure if you have any advice for if someone is working in a hierarchical

[00:30:04] environment and they do see something and they want to say something.

[00:30:06] Is there...

[00:30:07] I was chatting with Anne Richardson the other day who had just one example after another

[00:30:12] of times when someone brought up something that was a potential patient problem or was

[00:30:18] a patient problem.

[00:30:19] And the response of the system was actually to blame that individual for the problem.

[00:30:25] And wow, my heart just started to bleed for some of these really mission driven people

[00:30:31] getting their faces smashed against the wall for daring to do the right thing on behalf

[00:30:35] of patients.

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

[00:30:38] I mean, whenever I think about this in the recent history, I consider the Redonda Vaught

[00:30:43] story.

[00:30:44] She's a nurse sedating a patient, I think for an MRI.

[00:30:47] And there were two medications.

[00:30:49] One was Vecuronium, which is a paralytic, and the other one was Versed.

[00:30:53] And because both of them started with VE, they were close together in the medication

[00:30:57] cart.

[00:30:58] She was supposed to give Versed to sedate the patient.

[00:31:00] She gave Vecuronium, which paralyzed the patient.

[00:31:03] The patient died.

[00:31:05] She self-reported this mistake and then she was criminally prosecuted for doing this.

[00:31:10] This was recent.

[00:31:12] We'll link to that in the show notes.

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

[00:31:18] Yes, tragic.

[00:31:19] Yes, she made a mistake.

[00:31:20] But I can almost guarantee you that at least one, probably more nurses, almost made that

[00:31:26] same mistake, but they didn't report it.

[00:31:28] Phew, that was a near miss.

[00:31:30] I'm going to get on with my day.

[00:31:32] But imagine if they had reported that and then there were like three or four reports

[00:31:36] of that.

[00:31:37] Somebody noticed and said, ooh, that would be a really bad mistake to have.

[00:31:41] So let's systematically try to create, you know, rearrange the medication cart or do

[00:31:45] something so that that sort of mistake can't happen in the future.

[00:31:49] Then that patient would have died.

[00:31:51] That nurse would not be facing a prison term.

[00:31:54] Wow, that is so horrific.

[00:31:57] You really have to think through the outcome you're trying to create.

[00:32:01] Is it to prevent additional deaths or punish a nurse who reported her own mistake?

[00:32:06] Because in a way, maybe we have to pick one because we can't have both.

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

[00:32:15] This big system is pushing everybody in a certain direction.

[00:32:18] I can understand how somebody who's, say, a medical assistant who sees something doesn't

[00:32:24] want to speak up or they don't feel empowered to contribute to the team.

[00:32:28] And I hope that people start doing that a little bit more.

[00:32:32] So if we're thinking about constructing our pieces of advice here, the first piece that

[00:32:38] we talked about was really contemplative of what do patients need?

[00:32:43] What's going to help?

[00:32:44] Second one is how do you support colleagues?

[00:32:47] Thinking about both of these two things simultaneously, you had mentioned waste.

[00:32:52] Where is there waste within the system that could negatively impact patient care?

[00:32:57] Example of this.

[00:32:58] There's lots of people not in exam rooms because they're walking around trying to get

[00:33:02] printouts.

[00:33:03] Time is a zero sum situation.

[00:33:06] So it's certainly a win-win.

[00:33:07] In order to achieve either one of those two aims, it does take trying to figure out how

[00:33:13] to build an environment that people bring up suggestions to continuously improve.

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

[00:33:24] everything and that there are certain capacity constraints.

[00:33:28] Even if you say suggest that you move that printer, you may not necessarily realize that

[00:33:33] IT has to come by and they have to rewire all the cables and then they have to remap

[00:33:37] the printer.

[00:33:38] It's something that seems simple often isn't simple.

[00:33:42] And so I think as somebody who's trying to do stuff like this, you also have to accept

[00:33:48] the fact that there are certain limitations on what you can do.

[00:33:52] There are capacity constraints and then not necessarily get frustrated about it.

[00:33:56] It may be a lot of steps for some individuals, but it's closer for others.

[00:34:01] So exactly.

[00:34:03] There's this compromise situation.

[00:34:05] One of the things we talked about team-based care being a part of this and doing things

[00:34:10] to really support and emphasize the team and the team-based care.

[00:34:14] So not getting frustrated by that.

[00:34:17] What's that African proverb?

[00:34:19] If you want to go fast, go alone.

[00:34:20] If you want to go far, go together.

[00:34:22] So the going far together is always going to take longer.

[00:34:26] But the other one that you had mentioned was the whole idea of moving this whole

[00:34:32] transformation thing forward.

[00:34:34] It's bigger than a boulder, right?

[00:34:36] It's probably planet-sized.

[00:34:37] So we each have to just be happy with what we actually can accomplish.

[00:34:43] Like we can't let perfect be the enemy of the good and mental health and just our

[00:34:49] motivation to keep doing what we're doing on behalf of patients.

[00:34:54] Let's really feel good about the pebbles that we have pulled out and fixed.

[00:34:59] Yes, absolutely.

[00:35:00] Otherwise you just get frustrated.

[00:35:01] I do feel like in a lot of environments it's the really good motivated people who are the

[00:35:06] ones that wind up leaving.

[00:35:07] I feel like this is a really important conversation to have because it's exactly

[00:35:12] those individuals, you know, the ones that are listening to this show that we really

[00:35:16] need to continue to inspire and be inspired in the face of all these contrary forces

[00:35:22] and just BS because it's this crew that's going to transform health care if anybody's

[00:35:26] going to do it.

[00:35:26] Well, and I think also one of the things that that just came to mind is it is really

[00:35:31] helpful to have like-minded individuals to be able to be sounding boards for other

[00:35:36] like-minded individuals.

[00:35:38] One of the things that I would love for you to do is create some sort of mechanism for

[00:35:43] people to connect and communicate with each other who are of like mind so that I don't

[00:35:47] feel like I'm the only relentless health value person in my organization.

[00:35:51] There may be some others.

[00:35:53] And I've certainly encountered others who have in some of the work that I do around

[00:35:58] the country.

[00:35:59] I mentioned your podcast and they said, oh yeah, I love talking to Stacey.

[00:36:02] And then that creates almost kind of an instant bond that, yeah, we know what we want to

[00:36:07] try to do and we know that we're both frustrated.

[00:36:09] And we also know that if we get too frustrated, we can count on each other to talk us off

[00:36:14] the cliff.

[00:36:15] That's such a lovely way to put it.

[00:36:17] And it really just emphasizes the importance of community just to have that kind of release

[00:36:22] valve, which could be a conversation with a colleague either near or far who is trying

[00:36:28] to push that same boulder down the hill.

[00:36:31] Feeling alone is so hard.

[00:36:33] It takes a village and we all have to work together and figure out how we are supporting

[00:36:38] each other. And maybe that's something that those of you who are listening to the show

[00:36:41] can really keep in mind and think about how on somebody's worst day, if we are there and

[00:36:49] able to say good on you, keep it up, you're amazing, that really matters.

[00:36:55] So maybe as our last piece of advice here, it's a commitment to support each other and

[00:37:00] to keep our eyes open for those who are trying to do better, do right, fix something, to

[00:37:08] just offer them a measure of our heartfelt support and thanks and appreciation because

[00:37:15] that actually maybe make all the difference in the world.

[00:37:18] Yeah, absolutely. And be able to have some sort of private mechanism to do that, because

[00:37:23] a lot of times you're hesitant to do this in like a public forum.

[00:37:27] But if you have some degree of familiarity and trust with somebody who thinks along the

[00:37:32] same lines as you and being able to pick up the phone or text them, I think that that

[00:37:36] will go a long way.

[00:37:36] I couldn't agree more.

[00:37:37] I mean, there's plenty of times where I'm about ready to throw in the towel any day of

[00:37:41] the week and someone just comes out of the blue and says, thank you or much appreciation

[00:37:46] or this was really meaningful to me.

[00:37:48] I can tell you just personally how much that really matters.

[00:37:52] Dr. John Lee, is there anything that you wanted to mention that you didn't have a chance to

[00:37:57] in the conversation today?

[00:37:58] Be happy in the small things, have conviction in the things that you think you want to do

[00:38:04] is right, that it is right.

[00:38:06] Keep plugging away.

[00:38:07] It may not turn around all at once.

[00:38:09] You may not be that person who pushes that boulder down the hill, but be happy that you

[00:38:13] may have contributed to taking one of those pebbles out.

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

[00:38:21] them?

[00:38:21] LinkedIn, probably the easiest place to connect with me.

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

[00:38:28] Thank you.

[00:38:28] Hey, if you are part of the relentless tribe working hard to transform health care in this

[00:38:33] country, I don't need to tell you that we need as many on our side as we can get.

[00:38:38] The most vital thing that you could do to help expand the reach of this show is to leave

[00:38:43] a rating or a review on iTunes or Spotify and or share this show with colleagues or

[00:38:48] decision makers.

[00:38:49] Personally, I cannot appreciate it more when I see the reviews and they really count

[00:38:54] towards our search rankings.

[00:38:56] Thanks so much for listening.