Fixing Healthcare… From The Trenches (Episode 7)

Dr.Badia (00:02):

Good morning. This is Dr. Badia again with another episode of Fixing Healthcare from the Trenches. This week we have another, young colleague who’s actually in his training. Dr. Zachary Goldstein is an orthopedic surgeon, trained in Indiana. He’s an indie boy all the way, so I’m sure he’s pretty good in basketball. And he’s doing his spine fellowship at a very prestigious place in Michigan William Beaumont Hospital long reputation of spine surgery. And we are going to be talking about his generation of surgeons as they’re going out now into this increasingly complex, healthcare system. What’s unique about Dr. Goldstein, who should join us now, is that he is educating patients. I think that’s the key thing about our system. He’s doing it largely through humor.

Dr.Badia (01:00):

So at the end of the podcast, make sure you follow him. One of my favorite videos is where his daughter who’s gosh, well we’ll ask him now. She’s, she’s quite young, very, very precocious and is complaining about things that surgeons say in the operating room. And it’s, it’s just hilarious. So you can search for it on his site. But again, I think what attracts people is humor and at this point in healthcare, I think doctors, nurses techs have to have to kind of have to have a little bit of humor, but that doesn’t mean we have to stop fighting. So, Dr. Goldstein, welcome, welcome to our weekly podcast.

Dr.Goldstein (01:48):

Thanks Dr. Badia. Thanks for having me. I just want to add, you know, I’ve never really been tall enough to make it to any basketball team, so that’s why I chose medicine. And I’ll, and I’ll be honest, you know, as we all know, it’s, it’s really no money in medicine these days. So, you know, I’m hoping my ticket is going to be my daughter making it big in Hollywood, so I’m just kidding.

Dr.Badia (02:08):

That’s interesting because you, you know, you’re going into spine surgery, which is, still one of the areas of orthopedics that can be, you know, well compensated as it should. People don’t realize you do some of these cases, I remember as a resident, I mean, you’re standing up and it’s physical for eight hours, and if something doesn’t go right, which in anything, in the world nothing is a hundred percent. If something doesn’t go right, there’s a lot of stress. Right. So you know, in the end, you, you deserve to be well compensated for that. You’re going through long training. So I, I’d love to hear your perspective on your training and what your thoughts are for your future.

Dr.Goldstein (02:50):

Yeah. you know, I’ve loved my training. You know, I’ve done my medical training at Indiana. I’ve had really good experience there and now it’s interesting seeing, you know, a different location. Different hospitals now for fellowship and I’m going to be starting practice soon in a couple of months. I’ll be going back home to Chicago, actually, where I’m from. I think this is a really critical time for healthcare just because there are so many challenges that we’re facing now. I think the recent pandemic sort of just accentuated these challenges. But, you know, staffing challenges and burnout amongst, hospital staff is all relevant pretty much across the country right now. You mentioned, my social media I started it mainly for fun.

Dr.Goldstein (03:41):

But, I think it’s important that, we find humor in what we do, especially given how hard everyone in healthcare is working these days, and then also I think it is, it’s important for us to be self-aware of how we are perceived, you know, as surgeons, nurses, staff in the hospital because we need to be self-aware of this because even in jokes and humor there’s always usually a kernel of truth in any joke. So you know if a surgeon may act a certain way, for example, and there may be a negative way in which they’re perceived by staff, it’s fun to joke about it, but it’s also important to kind of be aware of that. So, we can correct that and make for a better work environment for everybody. And so, you know, part of what I’ve done in my videos is, I try to just find humor in just daily interactions in the hospital, whether it’s nurses or doctors or staff in general for entertainment, but also hopefully to promote some awareness and some areas for improvement.

Dr.Badia (04:42):

Well, I love the idea of self-reflection the, the video of where you’re fixing a fracture, or I should say your daughter is a surgeon and you are the scrub tech, which is the surgical tech who’s the very important person in our surgery, particularly in spine and also in hand. They’re very technical surgery, so they’ve got to know their equipment really well. I just had that scenario last week where I needed a reduction clamp and you know the staff said, well, you managed without it . So I just, I just had to chuckle because we can all relate to that, right? And it is a team, it’s really like a symphony. I’m excited to say I’m leaving. I got to be at the airport in about an hour and I’m operating tomorrow, but I’ll tell you, I’m operating, I’m going to give a plug to the Gramercy Surgery Center. They are in Manhattan and I’ve only done, you know, a couple cases there and they’re right on target. So I think the public needs to understand that all of these components in healthcare are really necessary for us to be able to take care of people and I’m hoping that’s why I love the humor that you bring, is that maybe that’ll get the public a little more interested, because a lot of what we do is perceived as being a bit boring. Right. Although there’s a pimple popper, right. Who seems to be I mean, I’d love to see, you know, people understanding your spine surgery, which is, I, you know, personally, I think a little more complicated

Dr.Goldstein (06:11):

I don’t know what it’s about popping, my wife is a big fan of that, that, but I don’t think spine surgery will ever garner the amount of interest as, you know, popping a, a big juicy pimple does for the general public,

Dr.Badia (06:23):

I guess. But well, but the thing, the struggles that you go through in order to be able to deliver that care, and that’s let’s talk about that for a moment. I mean, you are entering, you finish your fellowship and going to Chicago to practice. You are entering a climate where much of what you need to do for a patient, you need to be second guessed and you need to have, you know, authorization by somebody that doesn’t have a clue about this stuff. And, and it’s not their fault either, right? I mean, I’m not, I don’t think any of us are angry at these people, but we are a little angry at the system, right? Nobody is more qualified than you at this point, unless it’s another spine surgeon. I’m certainly not qualified. If you order something or you do, you do a certain procedure, you’re not infallible, but you are the best person to make those decisions. So what are your thoughts about how we can overcome that?

Dr.Goldstein (07:18):

It’s frustrating to see for sure, because I’m still in training, I’m not involved with a lot of those calls. But I’m certainly seeing it. I’m in clinic with my attending physicians and they’re ordering, tests for scheduling surgeries and then patients are being denied for any number of reasons. Some are, some are not justified and then patients are frustrated because they can’t get the care they need because an insurance company, for example, or someone has deemed it unnecessary.

Dr.Badia (07:51):

Experimental. .

Dr.Goldstein (07:53):

Love that experimental. It’s definitely the case in spine surgery. I mean, there are so many procedures that you have to document everything so exact and there are certain key components of things you have to document in order to sort of sell, the surgery to whoever’s going be paying for it to cover it and it’s sort of becomes a game in some ways.

Dr.Badia (08:13):

Frustrating. Yes, it is. And, and what, what I think is most frustrating for us as clinicians and caregivers is that the patients take it out on us and they have to realize that we’re in the same boat, right? We, we want to provide care, and this is our profession. They need the help. And yet, when they’re denied, the patients often express their frustration to be given. Not just to me, but like to my staff who really has nothing to do with it. They’ve got to sit on hold waiting to speak to, to a person at a desk somewhere else in the country about a patient I’m seeing at that moment. That’s very frustrating. So I’m hoping that the public who watches this, please channel that frustration to the insurance company or to your employer who decided upon that insurance company. So they, they understand that, you know, we are trying to help. And when they complain to us, it just it just adds salt to the wound because we’re in the same boat. So, you know, there are obviously a number of challenges in healthcare. So what are, what would you say are three initiatives that you, would, you would like to see in order to really fix healthcare at least, at least make a dent?

Dr.Goldstein (09:28):

Yeah, that’s a good question. I mean, there, there are so many things. Where to start, you know, I think one thing off the bat would be better price transparency. So, you know, you can’t go to you know, a drive-through and order a hamburger and then, you get to the window and you ask how much it costs, And then they say, yeah, don’t worry about it. You know, and then you eat your hamburger, you come home and you get a bill in the, in the mail three months later, you know, send, it costs a thousand dollars. You know, if you had known it costs a thousand dollars, you would’ve never gone to that drive-through. There have been recent changes. You know, there’s been legislation, enacted as recently as 2021, hat requires hospitals now to be transparent with, least some of the more common procedures they offer and kind of the negotiated prices that they’ve negotiated with the insurance companies. The problem is that a lot of hospitals are not compliant with these new regulations. And it’s actually shocking. Some studies have shown that like in orthopedics, for example, those compliance rates are even as low as like 20 to 30% of hospitals are compliant and it’s not even about having price transparency hidden somewhere in the website, but it needs to be, you know, easily obtainable for patients. I think if we started cracking down and making, you know, prices more transparent, that would create an open competition that would drive down prices and costs. And patients can be much more, you know, educated, and make informed decisions about where they’re going to be getting their care.

Dr.Badia (10:48):

Well, we’re going to try to get some legislators on here. Unfortunately, They’re going to be also clinicians, physicians because they’re ones who, who understand it and, and care the most. But, you know, podcasts like this, and there are others are really going to hopefully, you know, awake some eyes because for one, the hospital lobby right, is very powerful. So, you know, there is a film called The Swamp. I haven’t watched it yet, but The Swamp basically talks about how much of Washington’s controlled by lobbyists. The American public has to just say enough. I mean, you know, healthcare is up to 20% of our GDP now. Absolutely transparency. I’d love to get Marty Makary here who wrote “The Price We Pay” he talks exactly about this with big hospitals.

Dr.Goldstein (11:44):

Hospitals that are the biggest offenders. You know, the ones that are classically ranked as, you know, the top ranked hospitals in the country. Those are the ones that sometimes are the least transparent and actually charge the most.

Dr.Badia (11:53):

Yeah.I have to be careful. I’m going back to New York to my roots, so I got to be careful when I , you know, that’s a problem. A lot of physicians you know, even me right? you know, a little afraid to speak out, but you know, enough is enough. We, we really do need to explain. So, alright, so initiative number two.

Dr.Goldstein (12:10):

Initiative number two, I think, you know, this is a more recent issue, but just the staffing shortages in general. It’s, it’s crippling hospitals.

Dr.Badia (12:18):

Surgery centers, you’ll, you’ll see when you get out there, even, you know, even even my surgery center.

Dr.Goldstein (12:23):

Yeah, You know, nurses techs, janitorial staff, everybody’s been leaving the workforce. Some of them are going, choosing to travel for better wages.The cost of turnover and training new people, hiring, traveling, nurses, that is a huge, tremendous cost and staffing shortages, you know lead to, you know, surgeons of being able to, or not being able to do as many surgeries as they want. And so the end result affects patients and patient care. Healthcare in general, hospital surgery centers, they need to find better ways to really retain employees, nurses in particular because nothing can function without them. And so, you know, obviously higher pay would keep more people, you know, at their current jobs, but it goes beyond pay. You need to create a better work environment, or people in general. People are being stretched too thin right now. There’s burnout in the hospital.

Dr.Badia (13:16):

That’s bureaucracy. You know, you use the word burnout. One of the things I mentioned in my, in my book “Healthcare From the Trenches” I think in chapter 12 the title, it’s actually moral injury. I hate to use the word burnout because if you think about how hard you particularly during your, say your surgical internship, how hard you worked and you managed to do it right. So burnout is a little different. This is where you are, it’s akin to soldiers who’ve trained and they’re able to do it. But what, but when they’re told you have to go into this place and, and kill these innocent people that causes a moral injury. When we don’t get the authorization for that patient, or we’re hampered with our care and it’s not just doctors, other people are feeling it too, so that that moral injury takes a toll. So I agreestaffing is a big one. So number three.

Dr.Goldstein (14:13):

Number three, I would just say would be ways to improve efficiency and cost. And I think surgery centers are a tremendous opportunity. It’s happened over the past decade, the steady move towards doing more procedures in the surgery centers as opposed to the hospitals. You know, not every procedure, not every patient is right for an outpatient procedure, but certainly ones that can benefit from an outpatient surgery. Oftentimes surgery centers are running it, you know more efficient and cheaper costs than the hospital settings. I think we’re going to continue to see more and more surgeons bringing their surgeries to the ambulatory setting and that will, you know, continue to hopefully you know, decrease medical costs and utilization.

Dr.Badia (14:56):

Well get ready. Your spine surgery has changed radically, as you know. We have now two spine surgeons who come regularly to our center, which is literally, literally down the hall and I invite you, Zach, to come visit and maybe even spend a day with one of those guys. He trained in the, in the Midwest, and he’s done some front and back. So for a patient to understand what that is, is a general surgeon comes in, he helps the spine surgeon open the abdomen, approach the spine from the front, right? And then we turn the patient over and instrument the spine from the back, right? So we’re doing that in our surgery center outpatient. Think about the cost savings of that compared to the hospital. So hopefully the insurance industry’s listening because, you know, and they’ll reach out to Dr. Goldstein in Chicago, who’s recently trained and knows, knows how to do these surgeries. So I agree that is a big one.

Dr.Goldstein (15:49):

Absolutely. And, I have to take you up on that offer because I gotta get out of the Midwestern winter

Dr.Badia (15:54):

. We’ll try to come visit us before before March or April.

Dr.Goldstein (15:58):

Absolutely.

Dr.Badia (15:58):

Set that up. So I’m going to tell you my three initiatives. They, they don’t change, although I agree with everyone you said it, particularly the last one. Everyone who knows me knows I’m a big proponent for outpatient care obviously for hand, but now we’re seeing it in spine and we’re doing total joints as well. Hip and knee replacements, outpatient. So my, my first one is related to that is see the right clinician at the right time. Okay. Seeing the right type of physician or even, you know, mid-level provider at the time that you need, it saves a lot of money because you make the diagnosis earlier. You, you do the, the treatment plan and that, that saves money and obviously is good for the patient. The second one we touched on is let’s have oversight, not authorization, meaning we’re not infallible. Obviously there are, there are bad apples everywhere. There may be physicians who say, order too many tests or maybe do, do some surgeries when maybe it’s not a hundred percent indicated. So that oversight is fine, but don’t interfere. So let’s get rid of authorization completely. Let’s just get, get rid of that. The third one is what we’re doing and what I love that you’re doing through humor is educating the public. So whether it be podcasts or even, we do a lot of live surgery. Every two weeks. We do a live surgery #livesurgerytuesday. So on Tuesdays you can see that, and that is a way for the public to get engaged, but I love humor. That’s why I had you out here. So I did not tell you that I’m putting you on a spot if maybe you have a joke or something humorous to share with us, or maybe something that happened that you found very funny.

Dr.Goldstein (17:38):

I don’t know. I have to think about that. We had, one of the surgeons had a good line the other day there, you know, in surgery we like for the blood pressure of the patient to be a little bit lower, so little bit bleeding. So there was a little bit of extra bleeding in the beginning of surgery and he turned, turned to the anesthesiologist and he said, what’s the blood pressure? And the anesthesiologist said, you know, 160 over 110, which, you know, for those watching, that’s a little bit high for surgery so he responded very quickly. So that’s what my blood pressure is about to be if you don’t get that bleeding

Dr.Badia (18:12):

. That’s great. That’s great. I thought it was pretty funny and our anesthesia colleagues get it because they know we are under stress, they’re under stress, but only about 1 or 2% of the times. Right. They get it and we, we work together and that’s, that’s what healthcare’s all about and I’m sure the scrub tech and the nurse, circulator chuckled and probably the fellow helping clean the room and turn over.

Dr.Goldstein (18:40):

Yeah, I was laughing under my mask for sure.

Dr.Badia (18:42):

. That’s great. All right. Well, Dr. Goldstein thank you so much. Keep those, those funny videos coming and with that intent of educating the public of what we are facing really from the trenches. Thank you.

Dr.Goldstein (18:55):

Absolutely. Thank you so much for having me.

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