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 absolutely delighted to have the opportunity for the third time to speak with my colleague, Dr. Michael Zemmer from Chattanooga, Tennessee, the other side of the world, a kindred spirit, who's also author of Modern Healthcare Deliverance or Debacle. Now, welcome, Mike. Thank you for joining me. Thank you for having me, Warrick. Look, again, just for those people listening, Mike has written a book, Modern Healthcare Delivery, Deliverance or Debacle. We've really covered aspects of this in the first two interviews, and the overarching premise is that really we're starting to lose the focus around the patient, the finances, driving management strategies that really don't have the patient at the centre of our concerns. And this is through a whole number of different ways. Mike has touched on it in these podcasts and obviously dug deep within his book. But in this third interview, Mike, I'd really like to cover a couple of main points. And one is your... feeling around the mystique of that one-on-one consultation that we have the privilege of having with patients time after time after time. I think there is something incredibly valuable in that process, and I think it almost is beyond words, and we often don't factor it in in the modelling for delivery of healthcare, though it's absolutely critical. What are your thoughts on all that? In anecdotes, probably answer the question best work. I remember practicing. If I took a day off in 30 years, it was a lot. I would come in wearing a mask. This is long before COVID. And I would have a cold or a sore throat. And I would see the patients on my schedule, maintaining as much distance as I could from them and still be able to do my job. And I remember when they would leave the office. They would see that, you know, I was a bit diaphoretic and whatever. They said, Doc, I'm going to say a prayer for you after I leave. And after they walked out, I thought about that. I think that's the relationship. They are saying a prayer that I get better. You know, this is, you know, fast forward 20 or 30 years later, and a patient might say, Doc, I had to move to another physician because you're just not in my plan, my health plan anymore. Goodbye. And so what happened in that 20 or 30 years? It was a change. And the change was partly brought about by the provider end and partly brought about by the patient's attitude toward what adequate health care should. It wasn't a change for the better. And again, we come around 360 again to the same premise. It's time versus money. The patient walks into the office thinking, I've waited six weeks for this appointment for my annual. I've got a whole lot of things to talk to my doctor about. And the doctor's thinking when the patient walks in, I've got 12 minutes to do this exam, get to the electronic medical record, put my note in and get to the next patient. So we're coming from completely opposite perspectives and viewpoints here. And where is the happy medium? Where do we actually meet to render optimal patient care? It's a tension. I think we all recognize that tension. I think it requires us to be cognizant and aware of so that we can at least control it from our end as best as possible. I think if we're not thinking about the importance of that interaction and that space, then it won't improve. For the sake of a quick story, because you're right, stories are terrific. I had a patient come to me a number of years ago. He was approximately 50-something years of age. He'd had a heart attack 10 years earlier, had not seen any cardiologist since. This was a man, it would be fair to say, who had a somewhat aggressive disposition. Now, one doesn't want to be judgmental, but he had quite a lot of tattoos. In fact, he came in with his cigarettes tucked in under the T-shirt sleeve. And when he walked in, he really had a face that looked like he'd sucked on a lemon as he sat in the chair and was radiating anger at me, actually. And it only took a couple of minutes, Mike. And I put my pen down and I said to this gentleman, I said, mate, because in Australia, that's what we call blokes, mates. I said, mate, I don't know you. I didn't actually ask you to come here. And you're sitting there. seeming like you're really angry at me. He said, oh, my doctor told me to come. I said, well, you know, if you want to be here, fine. If you don't want to be here, I don't want to keep you here. You're welcome to leave. So up to you. What do you want to do? So he calmed down, actually. And, in fact, this is the sort of thing that you could only do face-to-face. You could only do it face-to-face. Correct. Couldn't do it over Zoom. You couldn't do it over the phone. It wouldn't work. Anyway. He said, okay, doc, I'll calm down. And then he calmed down, all right. So he hadn't seen anyone for 10 years. I believed that I would never see this guy again. So I literally wrote a shopping list, a menu of things for his local doctor to do. And it was about a list of six, seven, eight things, you know, nitrates, blood pressure therapy, et cetera, et cetera, and a whole lot of stuff. The gentleman left. We took longer than 12 minutes. You'll be glad to know. So I'm in near a 30 odd minutes. And that was the end of it. I thought, well, okay. And onto the next patient. Honestly, Mike, about three months later, I walked into my waiting room and lo and behold, the guy's sitting there. I took a double take. I took a double take. I looked at him. I said, I didn't think I'd see you here again. He says, doc, you made me feel so much better the last time I thought I'd come back again. And go figure, eh? Go figure. Coupling excellent medical knowledge with person-to-person, laying on of hands, and communication skills, there's no substitute for the combination of those two things work. Well, he recognized that my role is to try and help him, and we did get to break that down, which was what? what allowed me to make a difference for him actually um so interesting i reckon that space around the consultation is incredibly incredibly important but one of the things that's really become one of my realizations in recent time and we've talked about this a little bit offline is that i'm very much in the space of prevention i'm interested in cholesterol levels i'm very interested in imaging I'm a bit obsessive compulsive about treating blood pressure, diet for weight loss and reducing sugar. Very particular about these things. And what's become really obvious to me as I look at it in more detail is that the way the medical system is set up is that we are rewarded much more for allowing people to get sick and then trying to fix them up than we are rewarded. for keeping them well. Do you see that or what are your thoughts around that? Historically, at least in this country, it probably emanates way, way back into the 30s with the advent of Blue Cross Blue Shield. The surgical lobbies that evolved out of the blues systems were Just that, they were surgically driven, Blue Cross and Blue Shield. And that got built into the system of reimbursement that a surgeon's time, effort, and services were much more valuable than evaluation and management, EM, cognitive services, if you will, rendered by providers like yourself and myself. And although there's been lip service to it in our country over the past two decades, And they've tried temporarily to change what's called the RVU factors for cognitive evaluation type services. They've never really breached the gap. Never, never breached the gap. Not between primary care and specialty and not between specialty and surgical or procedural oriented specialty. These are quantum leaps. different from each other with regard to the financial remuneration. And, you know, it's simply not just, it's just not a just way to do the system. And what happens is in our country, the healthcare services with regard to the providers becomes top heavy to the proceduralists. That's why, again, we have in primary care, the physician extenders coming in there because we just don't train enough. primary care, family practice, or internal medicine. Internal medicine has a specialty, in my opinion, in many areas of the country, is disappearing. It's disappearing. Once they pass their internal medicine boards, they're on their way to specialty and subspecialty training because the procedures that they're able to do have a higher degree of reimbursement, and it's just human nature. If we're going to spend the time and energy to get educated, we want to be reimbursed to the maximum that we can for that education. I think it's a complicated space, obviously. There's no question that if you've done extra training and you've got an extra skill set and that skill set really carries with it significant obligation or risk or responsibility if something goes wrong, then you should be remunerated for that. very good reasons for that the the thing that really disappoints me enormously is that there's a real lack of value put on the prevention space and you mentioned the term lip service in australia lip service is paid to prevention all the time everyone talks about it but but it's just not prioritized and i think it falls under the radar because it's It's not as exciting, actually. And the results don't ever seem to appear as, you know, as good. You know, I've had colleagues say to me, oh, your patients have loved you more if you let them nearly die and then you fix them up rather than keep them well because they just come back year after year complaining they're taking tablets. And it's a very different, the whole psyche around it is fascinating. It's a different mindset. It's a different mindset. While I would agree with your premise that the extra training perhaps in our country, the malpractice premiums, et cetera, associated with interventionalists of any type, surgical or medical, rates a greater degree of reimbursement. Does it rate three times reimbursement? See, that's the point that I'm trying to make. We've never been able to come to the point where we should, at least not in this country. And from what you're telling me, this may be a worldwide problem, even in those countries with universal healthcare. The other thing in that space that is a bit concerning in my view is that sometimes these procedures can be potentially done when the indication is a little bit shades of gray and may not be necessarily to the best outcome of the patient. If we look at the data and the research that should inform our decisions, but it seemed like a good thing to do at the time. And my concern is sometimes this might be driven by factors that are a little bit around reimbursement for the practitioner, the opportunity and everyone's there, the convenience, et cetera, et cetera, not necessarily for the right reasons. And I always think of Superman who was told by his father with great power comes great responsibility. And so I think if we've got If we've got these great skills, we've got to be so careful in our application and our use of them to make sure they really are being used in the space that we know is going to be beneficial for patients. Not think that it could be or even be doing it for our own benefit. So there's huge obligation there, I think. I talked about it in great detail in a chapter of the book where I give the example. I guess it was about a 35-year-old female who goes to the doctor complaining of chest and I guess it was right upper extremity discomfort. And of course, being pressed with his 12-minute visit, even though she had virtually no risk factors, goes ahead and skips the physical examination because, of course, it can't possibly contribute to his diagnosis. and orders a nuclear stress test. And the nuclear stress test shows a possible equivocal abnormality, which leads to a left heart catheterization, which leads to a complication of a pseudoaneurysm formation in her groin from the catheter. And I go on to say, had he spent two extra minutes on the front end during the physical and the history? obtaining the history that this discomfort always occurred at rest. In fact, it occurred more when she turned her head to one side and then got out his little hammer and did a little triceps jerk and found out that the reflexes were not symmetric and then ordered the appropriate test, perhaps an MRI, he would have helped the patient instead of hurting the patient. It's the example that I give, but it's so germane to what you've just said, Warrick. Yeah, that's true. Um, when, uh, what do they say? If the only, um, if the only tool you have is a hammer, then everything's a nail. Everything's a nail that looks like it needs nailing. That's it. Look, uh, Mike, I'm going to wrap up again. We've talked, uh, effortlessly and the time has just disappeared, but I'm, this is going to be the end of our three interview. sessions, and I thank you again so much, but I'd really like to wrap up with something that is the opportunity for the wisdom that you've gained, gathered, learnt over the years to share that. And if you've got a moment, here's your stage, what would you be saying to some of the young health providers who are just coming through and starting out now? Give me your spiel to these people. I would tell them that they've got a plethora of technology available to them, which was not available to many of us in years past. and meaningful personal conversation with their patient and their peers. Not subjugate that to the technological varlets, if you will, of fax, email, text, and their progeny, the electronic health record. Let those technological items serve you and you don't serve them. You're the master. They're the server. And I think they're wise words, Mike. And I think all the way through these interviews, we've touched on that fundamental importance of healthcare delivery being the doctor-patient relationship. and the doctor understanding and connecting with the patient in a way that allows them to recognize what the priorities are. And as you say, the technology, the tests, they all support what we do. And you and I both know from our experience, we don't treat test results. We treat patients. How true. Mike, I'm going to wrap it up there. It's been an absolute pleasure. all the way from Chattanooga, Tennessee. Thank you so much, Dr. Michael Zima. Thank you. Thank you, Warrick, again for having me. For those listening, a reminder that Michael's written Modern Healthcare Delivery, Deliverance or Debacle. I hope you found these series of podcasts as informative, as engaging, as entertaining as I have. Thank you for joining me. Please take care. Bye for now. And of course, 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.
