I am so focused right now on the intersection (or lack thereof) of mission and margin, so I’m taking a second listen to this episode right now with John Lee, MD, because it is so ridiculously relevant given that I am, as stated, on a bit of a tear.
For a full transcript of this episode, click here.
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This mission/margin bender kicked off actually, if I had to diagnose the root cause, it’s because of all of the conversations that happen after what I’m calling the trust through line episode (EP477). Because if you think about it—and I have—if we are talking about trust, what does that even mean? Like, trust to what end? And when you start distilling it down, you wind up with trust that someone is gonna do right by patients and purchasers and the actual clinicians providing the care that even if there’s a stack of Benjamins to be had by doing the wrong thing, we can trust that mission will be put over margin—or at least balanced with it in some kind of palatable way.
Right? That’s a big piece of what it means to be trustworthy in healthcare. “You are what you won’t do for money.” That was a headline to a Ryan Holiday article I read recently and wrote down, because … right?
Now, it’s one thing for each of us listening here to contemplate mission and margin, and that matters. But it’s quite another thing for this contemplation to happen at scale, at status quo consolidated health systems, carriers; many status quo, not transparent brokerages, PBMs (pharmacy benefit managers), TPAs (third-party administrators); status quo stakeholders across the board. But because of this, actions being taken at the organizational level may not mirror the mission/margin ratio that you or I might aspire to.
So, why this episode with Dr. John Lee, you may be wondering? How did this conversation get teed up for a Take Two in the midst of this mission/margin tear that I apparently am on right now?
Dr. John Lee talks about and gives some advice for individuals in a status quo, not transparent organization how to find a mission to feel good about.
I would also highly recommend listening to the show with Larry Bauer, MSW, MEd. It’s a Summer Short, and it’s called “Knights, Knaves, and Pawns.”
So, here’s my conversation with Dr. John Lee, and next week come back because I’m gonna continue the mission margin conversation with Ben Schwartz, MD, MBA—and it’s a really good one. So, come back next Thursday, too.
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. Cognitive dissonance is when what someone winds up doing, their actions, are in conflict with what they believe in.
Now, it’s harder to engage in cognitive dissonance the closer you are to patients because you see the impact up close. 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. Sometimes it’s legitimately difficult to connect the dots all the way down the line to the customers, members, or patients.
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?
When you are a person not suffering from cognitive dissonance, at least to the level of those around you, what do you do to not get, I don’t know, demoralized?
And look, 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 gonna 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?
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 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 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.
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 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.
Dr. John Lee is an ER (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. In the conversation that follows, Dr. 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.
Also mentioned in this episode are Ryan Holiday; Larry Bauer, MSW, MEd; Benjamin Schwartz, MD, MBA; Chris Deacon; Scott Conard, MD; Rob Andrews; Rishi Wadhera, MD, MPP; Peter Attia, MD; Kenny Cole, MD; Mark Cuban; and Ann M. Richardson, MBA.
You can learn more by following Dr. Lee on LinkedIn.
John Lee, MD, is both a practicing emergency physician and a highly regarded clinical informaticist. He has served as chief medical information officer at multiple organizations and has an industry reputation for maximizing the utility and usability of the electronic medical record (EMR) as a digital tool. He was the recipient of the HIMSS/AMDIS Physician Executive of the Year Award in 2019.
He has deep expertise in EMRs, informatics, and particularly in Epic. He has multiple analyst certifications, which gives him a unique advantage in delivering solutions to Epic organizations. He has helped several startup vendors and Epic organizations understand how to better use their Epic systems.
His vision is a healthcare system that is driven completely by transparent data, information, and knowledge, delivered efficiently.
08:05 What is cognitive dissonance relative to the healthcare industry?
09:23 What are the systems that start to bear down on individuals within the healthcare system?
10:15 EP391 with Scott Conard, MD.
11:50 EP326 with Rishi Wadhera, MD, MPP.
12:27 “The system has almost gamed them.”
15:44 How can alignment still be achieved in the face of cognitive dissonance?
17:12 EP431 with Kenny Cole, MD.
20:43 Why does it take more than one person to solve the dysfunction in the healthcare system?
23:01 What are some little changes that can help change the cognitive dissonance in healthcare?
24:57 Why is a hierarchical healthcare structure not necessarily beneficial?
27:12 The RaDonda Vaught story.
34:30 “Be happy in the small things.”
Recent past interviews:
Click a guest’s name for their latest RHV episode!
Kimberly Carleson, Ann Lewandowski (Summer Shorts), Andreas Mang and Jon Camire (EP479), Justin Leader (Take Two: EP433), Andreas Mang and Jon Camire (EP478), Stacey Richter (EP477), Charles Green (Bonus Episode), Ann Lewandowski, Peter Hayes, Yashaswini Singh, Dr Kenny Cole