Welcome to Dr. Warrick's podcast channel. Warrick is a practicing cardiologist and author with a passion for improving care by helping patients understand their heart health through education. Warrick believes educated patients get the best health care. Discover and understand the latest approaches and technology in heart care and how this might apply to you or someone you love. Hi, my name is Dr. Warrick Bishop, and welcome to my podcast and videocast station. I'm delighted to have the opportunity for a part two with Dr. Michael Zima, a colleague, a cardiologist, an author, and we're talking about his book, Modern Healthcare Deliverance or Debacle? Welcome, Michael, from the other side of the world. Thank you for having me again, Warrick. Look, by way of a brief recap in part one, if you missed it, Michael shared some of his background. He's been a cardiovascular physician for 40 odd years with academic positions, with administrative positions, and really through the eyes of experience and a realisation of a change in the landscape of delivery of care has started to realise some of the... some of the fundamental issues of healthcare delivery that are just falling by the wayside. Do you want to just touch on that momentarily? Because they're really the concepts that drove you to write your book, Mike. Yes, Warrick, thank you. Yes, the deterioration of the doctor-patient relationship with the emphasis upon the limited amount of time that providers now have. to spend with their patient. The rise of physician extenders, which play a necessary role in healthcare delivery, at least in our country, as the number of insured rises rapidly, both with the Affordable Care Act and even before that, medical school enrollment going up one half of 1% per year. not at all keeping pace with the needs of the community. And so we see a 5% per annum increase in both nurse practitioners and physician assistants to try to fill that gap. Many patients out there are just unfamiliar with who these people really are. They come in and they go to the office expecting to see Dr. Bewell. Dr. Bewell is not there. In walks a young lady with a million initials after her name, DNP, BS Lab, you know, and who is this young woman? What are her qualifications? How did we get to this point? This is all discussed in the book to try to update people so they can navigate. areas of medicine in silos that they're not normally permitted to enter as the patient. See, each of us in healthcare is in our own little silo. I, as a cardiologist, am in a silo, but my administrator is in a silo. My nurse is in her silo. My echo technologist is in his silo. And do we really all have a picture of how these silos need to interconnect? and connect with the patient to render appropriate healthcare. This is why the book was written to allow providers of all different types and the lay public to navigate in the healthcare system outside of their silo so that they can get a better perspective of the overall healthcare delivery. Some of this that you're touching on is really a deconstruction of delivery of care for the sake of cost efficiencies. And there's always that tension between time and money. There's always that tension. And really, I guess, would you see that as probably the overarching difficulty in trying to get that balance right? Yes. And again, I discuss some of these things in the book. You know, the fee-for-service model, which is the predominant model in this country. And, you know, you eat what you kill, quote unquote, and pardon, the patient should pardon me from that. We certainly don't mean kill in the literal sense. But, you know, the more you see and do, the better you get paid. We discussed some of the drawbacks of a system like that. But ultimately, yes, many, many clinicians. have come out and said, you know what? This needs to stop. We need to have a better solution. Down south where I am work, you know, if the average visit in this country is 12 minutes between provider and patient, I got news for you. Down south here, these people are just so friendly. You know, in 12 minutes, they probably aren't even done telling me about their grandbabies, let alone what's ailing them, okay? So, you know, It just does not work. And I proposed some answers in the last chapter of the book, but ultimately it involves a change in behavior on the part of the provider. Because when you think about costs, the provider is the ultimate gatekeeper. Without the provider, there are no services. Without the services, there are no costs. Without the services, there are no outcomes, no patient treatment, no patients getting better. So we are the gatekeeper, the providers. And the question is, how do you change behavior of providers in a way that satisfies the provider and yet contains the costs? And that's what I spend the entire last chapter of the book, trying to discuss waste in medicine, trying to discuss... the problems with the practice of defensive medicine and how that relates to waste, discussing the fee-for-service model, which is not the model perhaps used where you are, certainly not in many parts of the world. And obviously also the costs associated with the administration of health care. In our country, 28 cents on the dollar. goes to administrative costs, never, never goes into patient care. How can we streamline those particular costs so that we can get more into patient care and perhaps through that venue, increase the amount of time the provider can spend with each patient encounter? Yeah, I mean, that's a... you've touched on so many points there but one that sticks out to me immediately is this 12 minutes to provide a consultation and we were chatting about this offline because obviously we've got some similar views in this space but within 12 minutes you can barely connect with a patient you barely have the chance to really get a sense or a feel for where they're coming from because you and I both know that if someone walks into your office how do you feel we say they say we feel fine but of course they're not fine otherwise they wouldn't be in your office it takes a while to really speak connect and start to feel where that person's coming from and 12 minutes is really suboptimal you can't you couldn't even do a proper examination in that time I remember practicing back in New York. I certainly never gave a 12-minute consultation. I was probably the most inefficient provider in the network at that time. And I remember even doing a 40 or 45-minute evaluation and thought I had everything down pat on this patient. I was all set. And you know this has happened to you too. And as they're walking out the door, they say, They turn around and say, oh, by the way, doctor, did I also tell you besides shortness of breath, I get chest pain? You say to yourself, where have I been the last 40 minutes? No, that's exactly right. Look, there is so much in that space of delivery of care. And I think aside for that administration cost of nearly 30%, which is insane. The very essence of what we do is in the consulting room or by the bedside with sick individuals. And I think a priority around that is, or an awareness around that is critical for the best patient outcome, at least from our perspective. The administrators need to be kept to count, but we really need to be focusing on that connection with the patient and that opportunity for them to be aware that we're all on the same page. Yes, and we should treat the patient. and not the medical record, which unfortunately over the past 30 years has become the be-all and the end-all so that providers in this country can survive an audit from the third-party payers. Well, look, I'm going to take a little bit of a turn here. I did notice in your book you've got a chapter called Convenience Care, and that caught my eye. I wonder if you could just let the audience have a bit more detail about exactly what that chapter is all about and what you mean by convenience care. In that chapter, I talk about a number of different things. We talk about retail medical clinics, urgent care clinics. telehealth, and where the future of telehealth will take us. Firstly, on the retail medical and urgent care clinics. I remember during my training, we rather disparagingly would talk about these, which were just coming into their own as Doc in the Box. Oh, so you saw the local Doc in the Box, Mrs. Jones. And he or she told you this, and, you know, very pejoratively speaking about this type of health care. And yet, over the decades, I've come to believe these dock-in-the-boxes play a real role in health care delivery, at least in our country here. I've used them. I've sent my aged father to them. When you're waiting two, three, four days or more for an appointment with your health care provider, and the doc in the box is readily available within an hour or less, for minor types of complaints, they serve a need. The question is, do they reduce the cost of health care? Because most of them are less expensive than a trip to our emergency rooms. and perhaps even less expensive than a trip to the doctor's office, now that many of them are reimbursed by third-party payers. The problem with that theory is that often patients will go to the retail medical clinic, get a prescription or whatever, and then they'll follow up with their family physician. And so that's a second charge that gets layered on to the first one. And you wonder, whether we're really saving money or not, or is it just an extra layer that's there for convenience, but it's going to help sink the ship. As I told you, as the ship is now 18% of the GDP in the US of A, it's just not sustainable. But they do play a role. Telehealth, on the other hand, telehealth, I think we've seen the COVID epidemic. really bring telehealth to the forefront. Telehealth, I think, has immense possibilities. My problem with it, and I'm sure yours also as a cardiologist, is up until recently, at least, there's no laying on of hands. There's no physical exam. And while the history is of paramount importance in making a diagnosis, probably the most important thing, right behind the history. certainly far in front of the laboratory, is the physical examination. And how are you going to do a physical examination by telehealth? Now, I talk about in the books some very novel technological advances now, which are probably going to allow some limited physical examinations to be performed by low end, if you will, low compensated, if you will. healthcare individuals, technologists, technicians, et cetera, who will be able in real time to record high quality heart sounds, breath sounds, to look at ear drums, to look into throats and record video camera and send this in real time to providers on the other end, allowing them access to what previously had not been available, a good quality physical examination. There's certainly a requirement to look where possible for the use of technology to help us get resources to where they're needed. And with that, to a degree, an obligation to try and keep the costs down in doing that. So certainly this COVID experience has been interesting for me. There's been, for the first time ever in Australia, the opportunity to bill a consultation over the phone. Previously in Australia, our Medicare, which is a universal health system, has not allowed doctors to bill for phone consultations. Likewise here with our Medicare. But the advent of COVID has changed that, and it's been extremely valuable. And you can also see the downsides of it. So one of the values, of course, of people who are frail with difficulties with mobility, you're able to give them a call checking up on their cardiac failure because they've had a blood test collected by the pathology service who's visited their house. And you can do all that over the phone without them having to find a car park or find someone who'll bring them and so forth and so on. And you can even adjust their medications over the phone because you've because you've seen them prior and you know what you're dealing with but for first-time consultations I think it's a disaster and the very reasons that you're talking about because you you can't see that person you can't connect with them and particularly if that first consultation is complicated in any way whether it's zoom or whether it's over the phone it can go terribly wrong because Because that one-on-one face-to-face allows a very different sort of engagement. So I've had a little bit of experience in that space. You can see how it's really relevant and can be a beneficial thing for certain situations. You can also see some of the detriments. And of course, it could be abused. And I think that's what governments and payers would be concerned about. And of course, there's limited body language too. You and I are doing this conference and I'm looking at your face. There's a large part of your body that I'm not seeing right now. And body language during an interview with a patient is very important and offers multiple clues as to what they really mean by what they say. Look, as our first interview, it just rolls on so quickly. We've gone over 15 minutes, believe it or not. flowing past uh just in the interest of time i'm going to wind this up but i'm going to invite you back for a third interview if that's okay with you mike because i i'm loving this conversation i think it's really important i'm sure our viewers will be getting a lot from it and there's still stuff i'm very keen to speak with you about uh so if it's okay with you i'd like to invite you back for a third one for now i'd like to close off this podcast i'd like to thank everyone for listening thank you mike for joining us Thank you, Warrick, for having me. So I hope you found this an interesting opportunity to reflect on some of the important aspects of healthcare delivery. Thank you so much, Dr. Michael Zima. For those listening, thank you for joining me. If you have any queries or questions, drop us a line. Until next time, look after yourself and please don't die from a heart attack. Goodbye. You have been listening to another podcast from Dr. Warrick. Visit his website at drWarrickbishop.com for the latest news on heart disease. If you love this podcast, feel free to leave us a review.
