How would you describe your work to change health care?
I leverage both the baggage and the credibility that comes with working for years as a physician in today’s broken health care system. My goal is to use the platform we’ve created over almost eight years on Facebook, YouTube, and across social media, and the ZDoggMD “character” to shift people’s perspective about how to fix health care. First, I make the case that health care can be fixed, must be fixed, and it’s happening now. Second, I point out where in the world things are going in a direction we call Health 3.0.
The Health 1.0 of the 20th century was more art than science, and deeply paternalistic. The Health 2.0 of managed care, quality measures, and the EMR turned all of us — doctors, patients, and the whole health care team — into commodities in the assembly-line of “Medicine-As-Machine.” Health 3.0 transcends and includes the best of 1.0 and 2.0 while restoring connections and the primacy of human relationships. This new health care paradigm is long overdue.
I spend most of my time working on a massive social media platform of nearly two million health care people and invested patients who want to be a voice for health care transformation. I also see patients at a county hospital as a hospitalist and assistant professor of medicine at the University of Nevada-Las Vegas.
Why do you switch back and forth between the comedic and serious ways you present your message?
In the early days, the ZDoggMD persona was a way to speak out when I felt I had no voice. I did it through satire and through a bit of clownery because that’s how you get people’s attention online.
It evolved to me building our clinic in Las Vegas and running a model that I consider a signpost for where health care can go. Even though we didn’t get it perfectly right [with Turntable Health, a direct primary care program] and we had to close, that experience opened my mind to what great care could be. I realized that we need to do more than just satirize and complain about a broken system.
While it’s important to make something patient-directed like a rap parody about stroke symptoms, it might be even more important to catalyze change among health care people because of the thousands of people they touch every day.
But, if I’m serious all the time, I’m like every other talking head. It’ll put people to sleep and it’ll put me to sleep. I have an oppositional defiant personality. I think you need that in health care to trigger the next wave of change. There are very smart people doing a lot of great things, but they’re often terrible communicators. I understand medicine through experience and I can help with the communication, so that’s the role I want to play. Hopefully people come for the comedy and stay for the message and the movement.
You engage with millions of people on Facebook and Facebook Live. Why use a social media platform to share your message?
You can have what I call the “measurement industrial complex.” You can have people who are doing PQRS. You can have Press Ganey and the Joint Commission. If you talk one-on-one to any of the passionate individuals who work in these organizations, they will make you feel something about why these measurements matter, why safety and quality and the patient experience are crucial to providing good care.
However, the way these organizations communicate comes off as condescending, disconnected, and mechanical. It makes frontline practitioners feel like commodities. They are not motivating our hearts. Humans are intuitive, emotional creatures that need to feel something.
That’s my job. That’s why I can make a video making fun of Press Ganey, but I can also give a talk and say, “Here’s what the people from Press Ganey told me. It’s not about, ‘Did you get your turkey sandwich on time and your warm blanket?’ It’s about what we do with a mother who just lost a pregnancy in the hospital. What’s your process for talking to her? How do you help her grieve in the hospital? What do you say? How does the staff behave?” Now that makes you feel something. That is the important and the crucial nature of what we’re trying to measure and quantify. If we can improve on that, then we have done a beautiful service.
Communicating is key and we don’t do it well in health care. I think that’s the central reason we lost so much autonomy over the years, especially in this position as caregivers. We haven’t communicated with a good clear voice. It’s time to connect in a way that will be visceral, but also intellectually honest.
What’s missing from most of the discussion about burnout in health care?
Resiliency training, mindfulness programs, yoga, meditation, and taking more vacations are bandages. They’re all important things, but they are not addressing the root cause. In the quality movement, people talk about root cause analysis. If they could do that for “burnout,” they would see that the root cause is moral injury in our caregivers. They are having to do things and behave in ways that are contrary to their moral instincts, the reasons they went into health care. They are serving multiple masters. They’re serving the business. They’re serving themselves. They’re serving patients. They’re serving the government and serving the measurement industrial complex. It creates internal conflict that drives people crazy.
People are feeling miserable and disconnected emotionally. They’re not connecting to their patients. Their self-esteem, self-worth, and feelings of accomplishment are low.
To get at the root cause requires deep system change, deep culture change, and payment reform. How we structure everything in medicine doesn’t just have to be tweaked. You need to blow it up and rethink it entirely.
You helped found Turntable Health, a groundbreaking direct primary care practice in Las Vegas five years ago. What worked, what didn’t, and how would you describe the future of direct primary care?
Turntable was a grand experiment. We wondered if we could take a direct primary care approach where patients pay us directly and combine it with a direct primary care approach where we’re partnered with big businesses — who pay for their self-fund employees — and insurance companies — who pay to give their members access to unlimited, team-based, no co-pay, “all you can treat” family medicine.
We combined that approach with a team that included health coaches from the community, physicians, nurses, and social workers to provide mental health care. We had a studio on the campus where we could teach meditation, mindfulness, and resiliency. We had a teaching kitchen to show patients how to cook quick meals in a food desert on a budget.
Our front hall had a community space where people would gather and form social connections, because social isolation is such a problem. We were trying to address the social determinants of health while practicing evidence-based medicine empowered by technology designed to do its job and get out of the way.
What worked? Our patients were incredibly happy. We had great outcomes. We lowered hospital admissions by 50 percent, to use one example.
What did we do wrong? We were one clinic in downtown Las Vegas without an ecosystem aligned with our goals. The rest of the ecosystem is fee-for-service medicine, which means they want to do stuff to your patient. People behave according to their incentives and in Las Vegas, in particular, without a big academic medical presence, that’s how it works.
The second problem is we tried to do everything for everyone. We should have picked a demographic and a population and optimized to them so that it would’ve been easier for our staff to coordinate care. It was very hard to manage multiple insurance plans even though you don’t technically take insurance. You still have to refer patients. You have to be “in network” or you can’t order any lab tests, et cetera, et cetera, et cetera.
Finally, we had too much overhead. We tried to make it a very good experience for patients, but we didn’t need 7,000 square feet. We could’ve done it on a much smaller scale and the experience would’ve been the human relationship, not so much the facility.
There was a lot of learning on my end. But the main thing is the soil was not fertilized yet for Health 3.0. We were just one little sprout. You need a forest around you to support and align with the incentives that you have.
Despite the challenges, how would you describe the continued interest in direct primary care?
It’s reaching a tipping point. When you’re a pioneer, and you’re one of the first out of the gate, you’re going to get a bunch of arrows in you. We knew that would happen. But now look at what people are doing: Three percent of the American Academy of Family Physicians is doing direct primary care. Groups are springing up all around the country where companies like Hint Health are helping them manage patients well. You also have companies like Iora Health who partnered with us on Turntable, who are growing. They focus on Medicare Advantage and their goal is to take care of senior citizens effectively in a cost-effective way that’s about relationships, not transactions.
[Direct primary care] is working and we’re seeing it show up everywhere. My goal is to share it with the world because even the doctors who are in it sometimes have a hard time explaining what they’re doing. Is this concierge medicine? Is this medicine only for the rich? No, this is a transformative model, and a lot of people can afford it. And, for the people who can’t afford it, we should have a government program subsidize good primary care. If we did that, we would watch the spending pie start to shrink because great primary care prevents diseases, unnecessary admissions, referrals, testing, and duplication. Relationship-based primary care allows you to develop connections with the patient and you have time to practice sound, high-quality, evidence-based medicine.
Why do you still make seeing patients a priority?
Because being a doctor is who I am. When I was dependent on seeing patients for my livelihood it created distress because I realized I was in a broken system, and if I can’t practice the way I want to practice, then I was potentially doing harm. I had no choice because to get paid I had to click certain boxes in the EHR and stop looking the patient in the eye. I had to satisfy quality measures that don’t measure quality for this particular patient who is nothing like the patients in the randomized control trial upon which these so-called quality measures were based. I was slave to both algorithm and the superstition of old school “we’ve always done it this way” medicine.
Now, because I love medicine, and I love patient care, I still see patients. They don’t pay me. This is a purely voluntary thing. I get to spend time the patients and they remind me every step of the way about the importance of quality and safety. I teach the health staff about understanding and addressing the social determinants of health because we experience the consequences for our patients every single day.
What troubles you the most about the future of health care? What gives you the most hope?
What troubles me the most is that we don’t have the political will at the government level or in big industry to undertake the truly disruptive change that will save not only health care, but the country as a whole. Health care is almost 20 percent of our GDP and an anchor around our ankles. We need truly brave disruptive leadership to fix medical errors, poor-quality care, geographic variation in care, unnecessary testing and overtreatment, and undertreatment in certain populations.
What excites me is that we don’t need [government or business leadership]. In the vacuum left by the failures of our cowardly leaders, there are two million people — in my tribe alone — who share the desire to transform health care. They’re all different people. Nurses, CNAs, doctors, and health system CEOs. This movement will catalyze change in conjunction with our patients who are going to demand it and vote with their feet. That gives me hope.
Medical students ask me all the time, “Should I go into medicine?” They tell me, “All my mentors are telling me no.” I say yes. I tell them, “By the time you finish medical school, you’re going to help us build this amazing new system where you will not suffer moral distress because you’ll be practicing the way your ideals tell you. By doing good for your patients, you’ll be helping your colleagues, and helping yourself. And helping the country.”
We know bright spots are emerging. We know there are organizations like IHI that are on the right track. We just need a catalytic vehicle and a platform to communicate it to as many people as possible and then activate them in a grassroots, bottom-up way. We know in medicine top-down edicts and regulations and management leads to disaster every single time. But if we start from the people touching patients every single day and their patient colleagues, we can transform health care in a way that no other country has been able to do. If we improve quality, reduce cost, improve outcomes, stop moral injury, and improve caregiver satisfaction, it could be a beacon for the rest of the world. And I think it’s our moral obligation to do this.
Editor’s note: This interview has been edited for length and clarity.