The first thing I would do is change the health care record and what’s required of doctors for documentation. The healthcare record is, without a stretch, ruining medicine and the doctor patient relationship. About forty percent of doctors are burned out when you survey them, and a significant part of this burnout is from having to deal with the medical record and documentation. We need to simplify the note the doctor is required to write on each patient, and make billing for this visit simpler. The charting doctors have to do for medico-legal reasons as well as to satisfy random billing requirements is like dealing with taxes and the tax code. To make up for it, a lot of doctors are hunched over the computer while seeing a patient, typing away so they don’t have to stay up to midnight every night and document things later.
As a part of my interview series with leaders in healthcare, I had the pleasure to interview Michael J. Stephen, MD.
Dr. Stephen is the author of Breath Taking: The Power, Fragility, and Future of Our Extraordinary Lungs. He is an associate professor at Thomas Jefferson University in Philadelphia, and director of the Adult Cystic Fibrosis Center. He is a leader of numerous clinical trials and has been on the front line caring for COVID-19 patients — and also recovered from the virus himself. Over the past two decades he has studied advanced end-stage lung diseases and worked with patients at diverse locales, including a Massachusetts prison hospital and a pediatric HIV clinic in Cape Town, South Africa. A graduate of Brown University and Boston University Medical School, he lives in New Jersey.
Thank you so much for doing this with us! Can you tell us a story about what brought you to this specific career path?
I’ve always had two big interests in life, aerobic sports and science and medicine. An intersection of these two is the study of lung medicine. The breath is very important in sports, and as you raise your effort you can feel it is what sustains you. When your breath becomes short, you feel your effort flag. In medicine, the breath surrendered is almost certainly one of the most anxiety provoking thing that can happen. I recently had a patient describe it to me as, “You feel as if you’re in a place where nobody can help you.” I’ve dedicated my life to restoring the breath as a physician, and studying different reasons it fails from a research standpoint. I want to bring this knowledge to a wider audience, and have everybody appreciate the medical, scientific, and spiritual importance of the breath.
Can you share the most interesting story that happened to you since you became the director of the Adult Cystic Fibrosis Center?
The biggest thing by far that has happened to us in the Cystic Fibrosis community is the advent of a new and very effective class of medicines called protein modulators. Cystic fibrosis is a genetic illness, and from an early age patients are dealing with too much mucus in their chest. The excess mucus allows infiltration of bacteria and scarring occurs over time. Traditionally most cystic fibrosis patients did not live much past the age of 30. Over the decades, therapies improved but all they were doing was helping clear out more mucus. None of the medicines were treating the underlying genetic or protein defect in cystic fibrosis. In this case, a defective gene produces a defective protein. New medicines have emerged in cystic fibrosis, starting in 2012, which help the defective protein work more effectively, so a lot of mucus is not produced in the first place. These have revolutionized the care of cystic fibrosis patients, and now the average survival is almost 50 and going up. Their cough, mucus, exercise tolerance and quality of life is so much better since these new medicines became available. Patients have been able to come off transplant lists, and instead of coughing through the night they are now sleeping soundly. It been amazing to watch this transformation as a doctor, to see this miracle unfold before my eyes. I’m sure it’s been wonderful for the patients as well.
Can you share a story about the funniest mistake you made when you were first starting? Can you tell us what lesson you learned from that?
Oh there are many of these. Learning medicine, like all disciplines, involves absorbing a whole new language along with many idiosyncrasies of the field. It’s very hierarchical too, and back when I trained people were not shy about telling you what they thought of your work or if you made a mistake. It’s just part of the field, and you learn to grow a thick skin. A lot of it is meant to save lives, so you can’t argue with that. Probably the funniest thing I did was when I was a medical student I had to go tell a patient they needed a cardiac bypass the next day because their coronary artery disease was so bad. So I went into the room and had a long discussion with an elderly patient and her sister about this very urgent need for cardiac surgery. Except I had gone into the wrong room and told the wrong patient they needed a surgery!! Fortunately the senior physician realized the mistake when I came out of the room. We both went back in and apologized. They were relieved to say the least! I was very happy that the senior physician had my back too, and explained it was honest mistake. We all laughed inside the room, probably me the least, but it was a good lesson to make sure you have the right patient, no matter if you’re telling them news or giving them a blood transfusions.
What do you think made your medical practice stand out? Can you share a story?
One thing that makes a practice in cystic fibrosis stand out is that it is multi-disciplinary. When a patient comes to see us, they see not only a doctor, but a social worker, a nutritionist, a nurse, and sometimes a study coordinator. We are there for them for all aspects of their life. Medicine has just become too complex, the system to navigate too bureaucratic, for a doctor to be able to handle all of the problems and issues that arise on their own .When a CF patient shows up at our practice, they know they will be getting the best and most comprehensive care in the world. Often I am the least most important person the patient sees at a given visit. Recently we had a patient who had gained a lot of weight because of a new drug they were put on for their lungs. The drug was good because it helped his lungs, but it also made him gain a lot of weight. When we saw him in the office, we discussed basic weight loss strategies, but it was the nutritionist on the team, who is excellent, who worked with him that day, and then regularly over email for the next month. He lost ten pounds the first month, and then another ten over the next two. I work with great people who also have the time to take patient’s concerns seriously. It takes a village to practice effective medicine these days, and surrounding yourself with people who are as invested in the patients health as you are goes a long way.
What advice would you give to other healthcare leaders to help their team to thrive?
One thing I’ve learned that is very important in medicine is that your team wants you to be positive and upbeat, no matter what the situation. They want to feel valued as well, listened to. The attitude of the individuals of a team always reflects directly back to the leader. You see this all over the hospital. The departments where the leaders are good doctors and good communicators, if you go to the floor where they admit their patients, every single person on that floor will act with professionalism, from the unit secretary to the nurses to the nurse’s aides. If you go to a floor with not good leaders, you feel that right away as well, but not in a good way of course. It’s really uncanny. So to all the leaders, how you act and are perceived will automatically trickle down to everybody on the team. You set the tone for everybody.
Another thing to understand is the way we communicate with patients and answer their questions has changed radically in the last fifteen, even ten years. Patients today require that their questions be answered in a timely fashion, usually same day. They also want to be able to see a doctor within two weeks. If you are not able to provide this type of service, the patient is going to move on and find somebody else. Make sure your office can accommodate this type of responsiveness.
Another thing to impart to your caregivers is to consider how invested each patient has in each visit. They are there with a problem, and they want you to own it as much as they want an improvement. Patients generally want to try new things, and they really want all your insights. If there’s nothing medically to be done, talk about physical therapy, or mental health. There is a tremendous opportunity to intervene and encourage that we have been given as physicians, and don’t squander it. If you do, that patient will just go find somebody else who has some ideas they can buy into. Every patient encounter is a chance to impart ideas, to help people get the most out of their life. If you find yourself in front of a patient with a problem and you have nothing to say, no ideas, no encouragement to give, no hope to give, it’s time to find a new line of work. I would impart this idea to every member of your team.
Ok, thank you for that. Let’s jump to the main focus of our interview. According to this study cited by Newsweek, the US healthcare system is ranked as the worst among high income nations. This seems shocking. Can you share with us 3–5 reasons why you think the US is ranked so poorly?
So let me say first there are a lot of great things about the US healthcare system. We have great doctors, nurses, and hospitals. We have the best research system in the world with incredibly dedicated scientists. The number of papers we generate in the scientific literature is more than anywhere else, especially impactful papers. So it is shocking when articles come out that show we spend more money with worse outcomes. Granted, the situation is complex here with a diverse population. The first problem is we have no universal health coverage, so there are millions of people uninsured in this country, even with the Affordable Care Act. Those people are going to do a lot worse because of this. There needs to be a minimum coverage that people can afford so they get into the system, get their blood pressure checked, get prenatal care, get natal care, get diabetes care if they need it. The basics of keeping a population healthy are not exciting, but they do require steady, attentive work. The second issue is we are very inefficient, from the computer system to being able to prescribe medications. Each insurance company has their own bureaucracy, and this is duplicated needlessly many time over. The final point I will bring up is we don’t value primary care in this country. They are among the worst paid doctors in the system. We also don’t have enough of them, likely because medical students have been incentivized to do subspecialty care, often because of enormous debt they carry from both undergraduate education and graduate. The system that sets doctors salaries and reimbursement rates is completely artificial, and somewhat arbitrary. This could be changed very easily. A radiologist sitting in a room looking at X-Rays for an hour can generate as much income as a primary care physician who has to slog through a ten hour day and see twenty five patients. It makes no sense. We don’t value primary care physicians, and it shows in our bottom line.
You are a “healthcare insider.” If you had the power to make a change, can you share 5 changes that need to be made to improve the overall US healthcare system? Please share a story or example for each.
The first thing I would do is change the health care record and what’s required of doctors for documentation. The healthcare record is, without a stretch, ruining medicine and the doctor patient relationship. About forty percent of doctors are burned out when you survey them, and a significant part of this burnout is from having to deal with the medical record and documentation. We need to simplify the note the doctor is required to write on each patient, and make billing for this visit simpler. The charting doctors have to do for medico-legal reasons as well as to satisfy random billing requirements is like dealing with taxes and the tax code. To make up for it, a lot of doctors are hunched over the computer while seeing a patient, typing away so they don’t have to stay up to midnight every night and document things later. Patients, understandably, don’t like this. My wife recently went to see a doctor, and the whole time he was in front of the computer typing, never once looking up at her while she spoke. That was the first, and last, time she saw him.
The second thing I would do would be to give the United States government the ability to negotiate drug prices. Right now a lot of doctors are spending a lot of time getting prior authorizations for drugs for their patients. If we had lower prices, a lot of this would go away. But insurance companies are paying so much for medicines, they have to be a very strict gatekeeper, very often for drugs that are well accepted for the condition they are being used for. If we could lower drug costs, insurance companies would be able to reimburse for many more drugs, and the hassle of prior authorizations and begging insurance companies for medicines would disappear. I have a nurse manager who works with me full time, and she regularly spends anywhere from 60 to 80 percent of her time doing prior authorizations. Granted as a sub-specialist I use a lot of somewhat unusual drugs, but this is just a huge waste of time. I cannot imagine what I would do if I had to do all of that myself, which is the situation many doctors are in. I would have quit medicine ten years ago.
The third thing I would do is overhaul our medical malpractice system. It hasn’t been shown to either improve medicine or patient outcomes. Quite clearly, it is harmful, as those who legitimately deserve compensation rarely obtain it. Unfortunately, it’s more about the quality of the lawyer you have, not the type of injury, that determines if you obtain a settlement. The best situation would be for a counsel to be set up, made of medical experts, to assess any potential issues in a fair and balanced manner. With this new system, the premiums physicians pay for malpractice would drop dramatically, saving the while system a lot of money. Recently a friend went through a brutal malpractice case which basically consumed all his energy for a year. He couldn’t focus on his research as he was worried about the case. Fortunately, and appropriately, the case was dismissed, but it cost him a year.
Improving coverage and portability of health insurance is another huge issue in medicine. Many patients have no health insurance, and are scared to come and see doctors or come to the hospital until absolutely the last minute. Hospitals lose a lot of money because of this, and of course patients have worse outcomes. It takes up a lot of our time in the outpatient practices as well as we work to get our patients the health coverage they need. We need good plans too. In a lot of these plans there are just too many deductibles and copays. They forgo medicines because of this very often. The United States started using these deductibles and copays on prescription medicines to help keep costs down. Well, clearly it hasn’t worked, and actually seems to lead to worse outcomes. So let’s get rid of them. Just recently in the hospital a very sick patient, on a lot of oxygen because of a pneumonia, insisted on leaving because he just retired and his new insurance had a very high yearly deductible. He naturally didn’t want a single hospitalization costing him a significant portion of his hard earned savings. He left on a lot of oxygen without having received all of his intravenous treatments. It was not a good feeling watching him shuffle towards the elevator as he left.
The final thing I would do would be to open up more medical schools in the United States, and figure out how to make them less expensive. Right now we import about twenty five percent of our healthcare workforce. That’s not necessarily good for the countries where these doctors are coming from as it’s an intense drain of talent. We need to invest in people here, and get them excited about medicine. Today we have many students leaving to go to school abroad, often in the Caribbean. We should be able to keep them here and train them here in an affordable manner. The talent is there, we just don’t have the slots to train them. We just need more medical schools, and bigger classes at the medical schools we have.
What concrete steps would have to be done to actually manifest these changes? What can a) individuals, b) corporations, c) communities and d) leaders do to help?
Most of what I talk about above has to do either with the direct interplay between hospitals, insurance companies, and drug companies, or indirect interplay between them. Those who are getting good money out of the system now, namely insurance companies and drug companies, aren’t going to want things to change, so it’s a very difficult system to reform. We saw the problems the Affordable Care Act went through at the political level.
The biggest hope I see for reform is from, not surprisingly, big technology companies. There are some radical things going on out there now. Technology corporations are realizing they are paying way too much to outside insurance and pharmaceutical companies to manage their healthcare needs, and cost projections looking into the future are not encouraging. As a response, these companies are forming their own insurance companies and spearheading their own medical efforts to keep this huge chunk of money to stay in house. They’re doing it quietly because they don’t want to attract a lot of attention. The biggest of these so far is Haven Health, a joint venture between Amazon, Berkshire Hathaway, and JP Morgan Chase. Atul Gawande is the CEO. He is a surgeon from Boston who has written extensively on how to improve health care. Amazon has also launched Amazon Care that offers its employees primary care visits on demand and a prescription drug delivery service. These companies aren’t going to wait around for the government to fix the situation. They are going to act, and have started to already, to keep health insurance money in house. Part of the reason President Obama was able to pass the Affordable Care Act was because business leaders got together and made it clear this was an issue that was affecting their bottom line. Medical costs are taking up too much of our GDP, money that could be going to funding new ideas, science or the needs of the people.
For an individual or a community to make a change on the scale that is needed is very difficult, but there are many things that can be done. Foremost, we need to make healthcare part of our national discussion, and there is no better time to do this now as we see the impact of lost health on society with the COVID pandemic. Never has it been clearer that we need a national healthcare system that is able to get everybody the best care in the world. We need to elect leaders who believe this is a big issue. There are both conservative and liberal reasons for it. We can’t have all the money of the country go into healthcare, we need a healthy population to work and be productive, and it’s a moral society that takes care of its citizens and doesn’t let five percent, or one percent, of the people take over all the resources.
I’m interested in the interplay between the general healthcare system and the mental health system. Right now, we have two parallel tracks, mental/behavioral health and general health. What are your thoughts about this status quo? What would you suggest to improve this?
Mental health is a massive problem in this country right now, probably the biggest medical issue after COVID-19, which is of course exacerbating it. We saw a decline in life expectancy during the 2010’s for the first time in decades, and it was because of two things, drug overdoses and suicide. We are driving down life expectancy because of mental health issues. So as the medical and scientific industrial complex plows ahead with genetic manipulation and new medications to treat rare diseases, the general population is suffering in a massive mental health crisis.
This crisis is not something that primary care doctors, as well as medical specialists, are not prepared to deal with. They don’t have the time, the knowledge, or the resources to take on this national crisis that is dragging down our life expectancy. As a lung doctor, I know I don’t have the knowledge or the resources to deal with this effectively in my patients.
Mental health is something that needs to be addressed at the primary care level at least yearly on every patient. To do this, though, it would be a huge mistake to somehow put this burden on the internal medicine and family medicine doctors. There needs to be funding for a social worker or other trained professionals, possibly even imbedded right into clinics and not as a referral. If having people embedded in the clinics is not feasible, having people to refer to would even be a huge upgrade. There is a dearth of mental health professionals, from counselors to psychiatrists. Insurance companies also don’t want to pay for it, and restrictions are often in place. Our mental health care in this country should be a national scandal, but it’s not.
The cystic fibrosis community is very forward thinking in this regard. Given that patients with cystic fibrosis are born with the heavy burden of a genetic disease, issues of depression and anxiety are very common. About six years ago now the Cystic Fibrosis Foundation began directly funding a mental health provider at centers throughout the country. As a part of this, every patient at every visit gets screen with a questionnaire for both anxiety and depression. The Foundation meant to give this funding only temporarily, but with the success of the program it is now a permanent part. It has been very successful in getting patients appropriately screened and to initiate referrals for mental health. As part of this program, we started a telemedicine mental health project which we have been able to show is as good as in person, and much more convenient. Something like this needs to be set up as part of primary care in this country. Telemedicine could be a big part of this. It would create a ton of jobs and help a lot of people. In our telemedicine study we didn’t use professionals to give the counseling, just students who were rigorously trained in ACT therapy, known as acceptance and commitment therapy. ACT is not a lot of psychoanalysis. It’s just asking what your problems and issues are now, trying to get people to accept things haven’t been perfect, but to commit to make changes now despite it maybe not being the best time. All you need would be motivated and educated individuals with an interest in training in this therapy, and you could have a very successful program. The labor is out there, the need is out there, it will just take a good effort from people to make it happen.
How would you define an “excellent healthcare provider”?
There are classic definitions out there that still very accurately describe an excellent healthcare provider. An easy way I was taught as a medical student to remember the important aspects of this are the 4 C’s: competence, communication, convenience, and compassion. If a physician can stick to these four traits, they will more than likely be very successful.
It’s good to keep in mind, though, that times have changed. Patients want more engagement from their medical team than ever before. They also have more access to information than ever before, so you have to think how I am offering anything better than what they can find on Google? The answer is, of course, a lot. The wealth of experience and knowledge accumulated with training is enormous. A computer or Google search will never be able to compete with that. But that’s our competition these days, and we have to contend with it. So the best thing is to make these indispensable traits known to your patients. Provide insight. Be enthusiastic. Be hopeful. Chart out a definite plan for care no matter what the situation. You can’t just sit there and say nothing. You have to try things. A lot will work, some won’t. But the key to being a good doctor is to get patients to buy into what your vision is for them. The first part of that is to have a vision. Get creative with your vision for each patient. As I mentioned, you may want to try things that may not be within the strict algorithms the insurance companies want to keep us in. Break out of those algorithms sometimes. There may not be a strict indication for an asthma patient to go to pulmonary rehabilitation therapy, but they may find it to be extremely beneficial. If the insurance company won’t pay for it, perhaps there’s something online that is affordable. Or maybe that asthma patient needs a referral to a speech therapist to help with breathing exercises. Ask yourself, why is this patient here? They have spent a lot of time and extra money to sit there in front of you, navigating traffic, time off, obtaining referrals. They are heavily invested in this visit, financially and time wise, and you should be as well. They want somebody who is passionate, invested, has a plan, and will follow up with them. Think about how you can individualize a plan to this person. What advice can I give this person to help them improve their life with whatever limitations and barriers we have here? People want somebody energetic, competent, who they believe cares about them and their health. Make sure you show this during the visit.
Can you please give us your favorite Life Lesson Quote? Can you share how that was relevant to you in your life?
My favorite quote recently has been “Tough Times Don’t Last, But Tough People Do!” It’s quite similar to the quote, “This Too Shall Pass,” but has a stronger, more active voice. It’s just a huge reminder to me in my daily work that problems will come up, and you’ll work on solutions, some of which might work, and some of which will not. Failing, though, is not an excuse to give up. My experience has been that if you learn from your past experience, you are going to be successful the next time. Just knowing that bad times will end, that there is mercy in the world, is so important for getting through a difficult time. Sometimes this means not doing anything in particular, just staying focused on your day to day, and trying not get too far ahead of yourself.
For me personally this has been relevant with the most recent COVID-19 crisis. When the COVID crisis first really hit the Philadelphia hospital where I work in April and May, everybody was very scared and freaked out. For the first time in our lives, there was great personal risk at work. Many people were dying in the hospital. The thought of a vaccine was just a pipe dream. Wearing a tight fitting mask in the hospital for twelve hours straight was difficult. It seemed like every day was the same, seeing a lot of very sick COVID patients and not knowing what we were doing. Sticking to the aforementioned life lesson quote really helped get me through the day and subsequent weeks. Finally, in June and July, things did get a lot better. I’m writing this at the end of November, and even though there are many people suffering, things are so far very much under control in the hospital. We are not all completely scared and freaked out. Tired, yes, but that feeling of being totally out of control, and not knowing when it would end, has certainly gone away.
Are you working on any exciting new projects now? How do you think that will help people?
I’m working on a number of new and very exciting projects. My wife is an immunologist, and studies inflammation, and I’m a lung doctor, so with COVID we thought it would be great to write a grant combing the two. We are analyzing the inflammatory markers in patients with COVID in both the lung and in the blood at the same time. What’s not appreciated by many people, and likely most doctors, is that our immune system is not one big conglomeration. The immune system of our body can be quite separate and quite different depending on what system you are analyzing. The inflammatory markers and white blood cells seen in the lung, the skin, the gut, and the blood can be very different depending on what’s going on in those individual sites. You can’t just draw somebody’s blood and know what’s going on in their body, or in a specific organ. Things can be quite separated. Viruses can take advantage of this, and they can hide in different parts of the body where the immune system cannot get to or access. The most common manifestation of this is chicken pox, which hides out the cells of our spinal cord, and later can come out in the form of shingles. Our immune system doesn’t dare go to the spinal cord and try to fight this infection there as it would be too dangerous to the body if it caused too much inflammation there. The point is that most COVID studies have just looked at blood markers of inflammation, but our grant will look at the lung as a unique system, and hopefully give us insights into the inflammation that is happening in our lung with COVID-19. This virus, even with a vaccine, is likely going to be with us for a long time, and understanding our bodies reaction to it is going to be very important. There may be some unique happening in our lung, an inflammatory marker we could perhaps target, that would help knock down this virus. An inhaled medicine would likely be the best thing as that mitigates any side effects of medicines going through the whole body.
What are your favorite books, podcasts, or resources that inspire you to be a better healthcare leader? Can you explain why you like them?
I really enjoy the big journals that focus on internal medicine, namely JAMA and the New England Journal of Medicine. They have really changed their approach to educating healthcare people over the past decade, incorporating a lot of web based interactive education, and making podcasts summarizing the latest literature and issues. A new kid on the block that I really enjoy reading is the Lancet Respiratory Medicine. This journal focuses exclusively on pulmonary medicine, and discusses a lot of global health issues as they related to breathing. It’s just so refreshing to get a perspective outside of the United States, where we’re always focused on the latest and greatest medicine. The Lancet Respiratory Medicine really talks about pulmonary medicine as it relates to the majority of people on the planet. All of these journals also show me the questions the leaders in the field are asking, and how they design their trials to answer these questions. A journal article published in any of these three journals is really a mini lesson on how to conduct interesting research as well as leadership, as most of these studies take years and sometimes a decade to finish, having to manage many people in the process.
I don’t really listen to a lot of popular medicine podcasts or read a lot of popular medicine books. I actually like to read some in the business literature, because of in terms of leadership skills, there are obviously a lot of lessons that can be learned. We haven’t accentuated leadership skills in medicine so much over the years, but medicine is much more consumer based than it was even ten years ago, and these skills are in more demand. One of the best quotes I remember reading in the business literature was that there is always a “better answer,” a way to really appear excited and engaged, a way to elevate your enthusiasm to match a task, to show you are truly invested in something. So after I craft an email, I read it to make sure my level of enthusiasm is really coming across. You only get so many opportunities, and if you don’t show enthusiasm people are just going to pass you over and move on to somebody better to work with.
You are a person of great influence. If you could inspire a movement that would bring the most amount of good to the most amount of people, what would that be? You never know what your idea can trigger. 🙂
My greatest passion in life is to keep people’s lungs healthy so they are able to take advantage of the greatest gift in the world — a happy and productive life. The biggest cause of lung disease in this country, and a huge contributor worldwide, is tobacco use. If I could inspire a movement that brought an end to tobacco use, that would be surely do the most amount of good for the most amount of people. I spend a lot of time in the office on getting individuals to stop smoking. It takes patience, and resources, and an individual patient has to be very committed to quitting tobacco, but it can be very rewarding. Larger scale projects that help with this can also be very effective. We don’t like as Americans to tell each other what to do, and how to live our lives, so it can be delicate subject. Smoking rates have declined massively from levels over 50% in certain groups to now a national tobacco use rate of around 14%. That’s a lot of progress, but still a lot of people smoking, about 34 million. I would love to figure out how to reach each and every one of them, and how to rescue the next generation from this toxic scourge. The message is getting very dilute recently, as e-cigarettes are getting the younger generation hooked on nicotine in massive numbers. They just don’t see it as harmful. The science, of course, says otherwise. Nicotine is not a drug we need. It’s not necessary to human existence in any way. I would love to inspire a movement to get that point across.
How can our readers follow you online?
The best place to follow me is at my website https://mjswriter.com
Thank you so much for these insights! This was so inspiring!