“Always do the right thing and surround yourself with other people who make ethical decisions.” With Dr. William Seeds & Dr. Marcel Brus-Ramer

Always do the right thing and surround yourself with other people who make ethical decisions. While you may get a small win now by doing something that’s a little bit faster toward your short term goal in both healthcare and business relating to healthcare, such fast decisions can hurt you in the long term. In […]

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Always do the right thing and surround yourself with other people who make ethical decisions. While you may get a small win now by doing something that’s a little bit faster toward your short term goal in both healthcare and business relating to healthcare, such fast decisions can hurt you in the long term. In medicine, you never know when you’ll run into people, but I can guarantee that when you do, they’ll remember you and they’ll remember the past.

As a part of my interview series with leaders in healthcare, I had the pleasure to interview Marcel Brus-Ramer, MD, PhD.

Completing his MD and PhD at Columbia University College of Physicians & Surgeons in Neurobiology in 2009, Dr. Brus-Ramer went on to complete his residency in Diagnostic Radiology at UCSF, the #1 radiology program in the United States. Upon finishing his fellowship in Neuroradiology at UCSF in 2016, Dr. Brus-Ramer became co-founder of Elite Medical Prep, now one of the leading 1-on-1 private USMLE and medical exam tutoring organizations. In addition to being the acting President of Elite Medical Prep, Dr. Brus-Ramer is also clinically active working as a Board Certified Neuroradiologist for a academic teleradiology practice that provides specialized radiology interpretations for several major academic medical centers including Duke, Johns Hopkins, Stanford, Northwestern, MUSC and Rush among others. As a function of his radiology work, Dr. Brus-Ramer holds medical licensences in 16 states, has an extensive academic publication record, and is also a guest instructor at Sackler School of Medicine at Tel Aviv University and Columbia University Physicians and Surgeons.

Thank you so much for doing this with us! Can you tell us a story about what brought you to this specific career path?

The way that I ended up in medical tutoring was brought about by necessity at a time of crisis for me. In 2009 I was an MD/PhD student at Columbia University and I finished early, in October. October was considered off cycle for the program, as I was supposed to walk in graduation in June of 2010 with the rest of my class. However, unfortunately for me, due to the medical school policies and the funding situation, it became clear that they would not continue extending my program.

If you remember, 2009 was the height of the economic crisis associated with the great recession in the United States. I was married and had 1 child and my wife was pregnant with our second child and I was this MD/PhD student in limbo before starting my residency when my wife lost her job. When that happened, I realized, we need to make money and pay for bills and my wife is pregnant, so I needed to figure out how to support us. I looked around for a job and I knew I did not want to continue doing more research, especially not research that was going to be only for 8 months before starting residency, so I ended up taking a job with this company that came along saying they did USMLE tutoring.

USMLE stands for United States Medical Licensing Examination and that was perfect because I had just taken and done well on those exams myself. After several years of working with that company, I realized with a colleague that we could probably do a better job doing USMLE tutoring than the company we were with. That was when Dr. Ken Rubin and I broke off and started Elite Medical Prep. As time went by and I really started to work hard to grow Elite Medical Prep and start to train tutors to teach medical exam material in a meaningful way, and develop curriculum, this “crisis idea” blossomed into a genuine passion of mine.

Can you share the most interesting story that happened to you since you began leading your company?

After we started Elite Medical Prep, in 2015, I was in Israel and by complete chance ran into a friend of mine on the street in Tel Aviv that happened to also be visiting Israel at the same time. He was someone I knew from a synagogue that I frequented in New York and we had had dinner before and got along quite well. After telling him about the new company, he connected me with his best friend from medical school who also (What are the chances?) happened to be visiting Israel at the same time.

The best friend turned out to be a radiologist and was a Mt. Sinai faculty member as well as the director for the Mt. Sinai USMLE prep course at that time. We became fast friends when we were in Israel and before he left I asked him if next time I was in New York I could come to see him teach the course. I ended up doing exactly that and I brought along co-founder of Elite Medical Prep Dr. Rubin to see what the course was all about. We watched the course and we took some notes on how he presented the material and learned some interesting stuff about how institutional prep courses work.

About 6 months go by and we keep in touch a little bit but nothing major related to the company or Mt. Sinai. Then one day, I get a phone call and he tells me, “Hey, I’m no longer going to be doing the course at Mt. Sinai, I’m moving to Arizona and I’m not going to have time for this anymore.” He went on to say that he wanted to offer an alternative to himself before he left and was wondering if he could give my name and company to the school. Based on that recommendation and that by-chance connection in Israel, we were able to propose to Mt. Sinai that we might take over the USMLE prep course. After some deliberation, they chose to go with us despite neither Dr. Rubin nor I being faculty members. Being chosen to do the course at Mt. Sinai has proven to be a tremendous opportunity for us as a company since that connection has led us making connections with other schools.

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?

Our business operates almost entirely online and a year or two after we started Elite Medical Prep, we ended up changing our website hosting domain from Weebly to WordPress. When we did that, we had quickly hired some developers, not knowing very much at all about the technical side of websites and they managed to accidentally wipe out our entire site history during the transfer process.

We actually had no idea that that had happened since at the time we were getting a lot of students and making good connections with schools. About 6 months down the line, our flow of new students started to taper off and we started trying to figure out what was going on. After thinking and thinking about why nobody was calling us for tutoring anymore, someone got the idea to do a quick Google search of ourselves and that was when we realized that our site history had been completely wiped and now instead of showing up as the top search result for USMLE tutoring on Google, we were lost somewhere on something like the 6th or 7th page of search results.

At the time, this mistake was just about as un-funny as it gets. However, now years later that we have recovered from what we comically refer to as, “The Great Site Erasure,” the whole fiasco is a funny lesson on why to always take time to do in depth interviews and hire professionals with references and track records of success. That mistake actually ended up being responsible for the creation of our marketing department and eventually after a lot of hard work and hiring professional web developers we were able to get ourselves back to where we were and maybe even set ourselves up for bigger success than we would have ever been. In retrospect, we probably also weren’t ready for the success at that time from a logistical standpoint, but we definitely are now.

What do you think makes your company stand out? Can you share a story?

Our honesty and persistence. This is something that we have encapsulated in the policies that we have towards both our students and our tutors that we’ve maintained since day 1. With our students specifically, one of our primary company values is to maintain the highest possible level of disclosure and honesty about what we’re capable of and what we’re not capable of, as well as what we can promise and what we can’t promise. With these exams, there are just no guarantees and we refuse to mislead our students by over promising or false advertising that on average we help students improve their score by X amount of points in X amount of time or what not.

I remember one of our first students was a resident in OB/GYN and needed help passing USMLE Step 3 (the final of the USMLE medical licensure exams) but had already failed several times. At that time Dr. Rubin and I were doing most of the tutoring ourselves and so I started working with this student. The student was responding to the tutoring initially but then started lagging and progress began to plateau. While students sign up for 1-on-1 tutoring which typically means 1 tutor is assigned to 1 student, we ended up bringing in another tutor to help supplement sessions and change up the teaching style in hopes of seeing student improvement again. We actually ended up coordinating a 3rd tutor because the student just had such bad test taking skills that we decided we needed a multifaceted approach. Finally after working with the student for a number of hours over several weeks, we were able to get his performance elevated to a point where he was able to pass the test. We learned later on that had that student failed that last attempt at Step 3, he would have probably lost his spot in residency. He came to us with his career on the line and we were able to help him save himself.

Recently I actually received a LinkedIn connection from that student and saw that he is now an attending physician in his specialty, OB/GYN, and it made me really proud of the effort we put into helping even very problematic students succeed. We have similar stories like this with lots of other students from over the years. There have been students who came to us in a total crisis where their medical school was about to push them out as well as students with multiple failures and 2 weeks left before their final attempt at the licensure exam.

I think that our policy of being honest with our students and being upfront that we can’t necessarily solve their problems gives students the refreshing sense of, “Wow someone is being honest with me.” Once we get to working with students, while we can’t promise them success, we truly use every means possible to help them succeed. Whether that means bringing in multiple tutors and coordinating things in that fashion just to help them pass, or using atypical learning strategies, or trying a variety of different learning strategies, or working in a crisis mode very rapidly to help boost their score, we do everything we can with every student that comes to us for help. That’s something we really pride ourselves in.

What advice would you give to other healthcare leaders to help their team to thrive?

I would encourage people to understand that relationships in the healthcare field are slow and long term. People have long memories and what you do now will reverberate throughout the rest of your work in medicine. If you’re planning to cut cords with certain people or organizations or you’re considering whether something is the right thing to do ethically or not, always go with the ethical version.

Always do the right thing and surround yourself with other people who make ethical decisions. While you may get a small win now by doing something that’s a little bit faster toward your short term goal in both healthcare and business relating to healthcare, such fast decisions can hurt you in the long term. In medicine, you never know when you’ll run into people, but I can guarantee that when you do, they’ll remember you and they’ll remember the past.

I’ve always tried to hold my behavior and my decision making in both business and medicine to the highest ethics because that’s just the way I like to operate. However, I’ve certainly seen the benefits of that down the road repeatedly when it comes to relationships and making other connections.

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?

As a neuroradiologist, in no particular order, three reasons that I think the US healthcare system is ranked so poorly is because (1) we have a lot of excess and waste procedures done, (2) a lot of doctors and healthcare providers are essentially forced into making decisions because they need to protect themselves against legal action or the perceived threat of legal action, and (3) we have an excess amount of expenditure on management and intermediary administration and that seems to drive up healthcare costs.

Beginning with excess procedures, in my experience, we spend a lot of money on unnecessary procedures and unnecessary imaging in order to “be sure” about any given diagnosis. Part of this problem can be attributed to our time pressures as in the United States we need to make decisions so fast in medicine that we can’t let medical cases “play out” on their own at the speed at which they need. Often, we end up imaging people extensively in order to be sure that we’re not missing anything, but also to drive to the answer of what could possibly be wrong with the patient faster. Sometimes those answers could come on their own naturally by just allowing things to just percolate a little bit. To be clear, this is not to say that a person after a car accident or shooting should not be imaged right away — they definitely should be. However, there are many people who come to the hospital with intermediate symptoms so they’re getting immediate imaging when they may be better off having some time to evaluate the condition in a deliberate fashion without jumping straight to imaging. In many cases, that could save a lot of money. Not because the imaging necessarily costs that much, (which it can) but because it would allow the lobby imaging to avoid being used and as a result not searching for other incidental findings that can then produce further follow up and trigger further cost.

Regarding the issue of legal action, for many doctors there is a fear of being sued. Part of the fear is not just the cost but the downstream effects a lawsuit produces often inhibiting a doctor’s ability to get licensed, get insurance, and to be able to work at other hospitals. Once you have a lawsuit, it causes a black mark against your record and makes it harder for you to register at other hospitals and move positions. This being said, lawsuits probably are necessary to help compensate victims, patients who have had poor care that may have occurred due to mistakes or to malfeasance by another provider, but it can’t be ignored that many people likely sue because they don’t have other recourse. The problem is that the legal system is being used inappropriately and in turn it drives doctors towards a form of practicing medicine that is designed to cover your bases and protect yourself against potential lawsuits or infractions. This means that physicians end up behaving in a way that is extremely risk averse, potentially over testing and over imaging, that can lead to excess numbers of additional tests down the road and drive up cost.

Management expenditure also seems to be an increasing problem in the United States. What we notice is that more and more hospitals and clinics are being run by larger and larger groups with larger and larger layers of bureaucracy. This creates a number of administrators that may be necessary to manage larger organisations, but increasingly so, there seems to be extra layers that are almost bloated. A lot of the pay and the salaries and such that are going to these levels of administration can also unfortunately take away from money that could be spent on care and clinical providers. So this is really a problem. Particularly, you see this issue in hospitals that are growing larger and larger and executive salaries are growing to the 6 and 7 figure digits for multiple members — not just the chief executive. In my personal opinion, it just doesn’t seem appropriate that people are being paid like that to operate a largely non-profit hospital.

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.

There are many changes that need to be made to improve the US healthcare system. The changes that immediately come to mind are as follows:

  1. Create a national healthcare license with centralized credentialing. I recently wrote an article about this topic and why specifically during a national health crisis such as COVID-19 one singular national medical license that would allow physicians to practice medicine across state lines and better respond to the pandemic. As an emergency teleradiologist, I work with a company providing remote overnight and weekend radiology coverage for more than 150 hospitals across the United States. In order to do my radiology work, I have to hold 16 different medical licences. For every hospital in every state in which we provide coverage, all of the teleradiologists must have a medical license in that state, in addition to a license from the state where they reside. Each of these states has its own unique license application paperwork and fees (which can get expensive), though largely most states ask for the same information and rely on the exact same test scores. A singular healthcare license with a centralized credentialing system would not only help keep licensure costs at bay, but also make it much easier for physicians to practice anywhere they are needed. With a national healthcare license, doctors from out of state would be able to better aid in crisis response such as that of a major isolated medical event like a large flu outbreak in a small town, medical care after a natural disaster, as well as countless other situations that could require bringing in extra medical professionals.
  2. Either reduce the cost of medical school or provide significant debt forgiveness to physicians. Debt is a major problem for many physicians and American medical schools are among the most expensive in the world to attend. Still, it is common knowledge in the medical community that graduates from American medical schools are much more likely to land residency spots than international medical graduates. Therefore, especially for those planning to apply into highly competitive residencies, going to an American medical school and incurring crippling debt is all but required. Since the cost of medical school is so high, we are seeing many doctors turn to higher paying specialties as a means to be able to repay their student debt. Reducing physician debt would likely allow more physicians to go into lesser paying specialties many of which are primary care related that are in some states experiencing shortages.
  3. Reform physician payment structure to de-incentivize excess procedures. The way that the current physician payment structure is in the United States is such that physicians make the bulk of their income from doing procedures rather than consultations and examinations. This feeds into both the excess procedure problem that I mentioned earlier in the interview as well reinforces why the medical student debt problem needs to be addressed. Many of the highest paying medical specialties tend to be the most procedure heavy which in turn creates this cycle of excess in the American healthcare system. If physicians could be paid simply for their time spent in keeping their patients well, with or without needing to do procedures, this would help to slow things down and allow certain situations to play out leading to potentially better outcomes while simultaneously allowing physicians to spread out more equally to different specialties.
  4. Teach physicians in medical school management skills. I mentioned earlier the problem of growing administrative costs especially at large hospitals. I think that if physicians were given more training in management, they could work more effectively with physician extenders such as PAs and NPs in clinical settings. With developed management skills, doctors could essentially manage a group of non-MD healthcare professionals as sort of “team leaders” so that patient coverage could be expanded to handle a higher volume of people. The PAs and NPs could handle the standard uncomplicated cases that come in under the direction of the physician, which would then leave that physician to deal with the complicated situations directly. This kind of system might be able to provide a way to help increase healthcare coverage without expanding overall cost incurred by having to hire additional doctors and hospital management.
  5. Cap administrative costs as a percentage of care costs. As the same procedures cost more and more money, physician salaries do not seem to be climbing in the way that some administrative salaries are. I think a good idea to help drive down healthcare costs could be to cap administrative salaries for both profit and non-profit hospitals as a percentage of care. Calculating administrative salaries as a percentage of the total care costs incurred at hospitals would help to funnel more funding toward patient care while cutting back on and capping non-clinical expenses.

Ok, its very nice to suggest changes, but 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?

Systematic change begins by large when a community steps up and demands attention to a specific problem. Change can also happen when individuals in positions of power act ethically and make difficult decisions advocating for change, however historically it seems community advocacy has led to greater outcomes. We are seeing right now how powerful community advocacy can be in the United States as we watch or participate in all the current mass protests against police brutality toward people of color and in support of black lives. When communities step up and shed light on an issue, it often forces leaders to make the difficult decisions that they otherwise may have avoided addressing.

In terms of what specifically can individuals, corporations, communities and leaders do to help improve the United States healthcare system, at all levels, I would say find the courage to advocate for change that will do the greatest good for the largest number of people. System wide changes are never easy to make, but in the context of the American healthcare system, many are necessary in order to improve the quality and cost of care in the long run.

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 problems can and often do affect physical health. This being said, I very much hope to see in my lifetime mental/behavioral health and general health just become health in the United States.

I think a change that would dramatically help merge these two tracks would be having mental/behavioral health covered in the same way that insurance companies cover general health. It is common knowledge that not all insurance companies cover mental health costs as part of basic care in the way that they would cover a broken arm or a visit to your general practitioner. Treating mental health the same as general health from an insurance standpoint would not only allow greater access to care, but also help to eliminate once and for all old stigmas. Such a move by insurance companies could also potentially pave the way for greater collaboration between mental/behavioral health professionals and general healthcare professionals.

How would you define an “excellent healthcare provider”?

An excellent healthcare provider is someone who has not only been trained well from an academic and clinical standpoint, but someone who continues to be inquisitive and genuinely interested in their work throughout their career in medicine. That doesn’t just mean doing the basic minimum to keep your patients alive and well, but it means looking at all measures of health and their interactions to provide the most comprehensive care possible. An excellent physician should also take their experience and willfulness to always continue learning and use it to help provide the best for not only the patient as I mentioned, but the community. Being a “good doctor” doesn’t just simply mean making people live longer. It means trying to help people to meet their goals from a health standpoint and thereby maximizing quality of life.

Can you please give us your favorite “Life Lesson Quote”? Can you share how that was relevant to you in your life?

My favorite life lesson quote that I use in my work would be, “Don’t just do something, stand there.” Which is the opposite of, “Don’t just stand there, do something.” When I was in the ICU as an intern many years ago, I remember hearing a doctor say this quote and the idea was that sometimes it’s better to stop and think about what you’re going to do rather than just acting for the sake of doing something. Not every situation requires swift and immediate action. Sometimes the delay in acting can actually allow you to make a much better decision if you pause for a moment to observe and allow things to play out. A little bit of thinking before you spring into action can be far more important and provide much more effective outcomes than acting fast because you’re under pressure.

Are you working on any exciting new projects now? How do you think that will help people?

We are always working on exciting new projects! The two major projects that we are most excited about right now are expanding the high quality customized USMLE courses that we offer to institutions and working to find tutoring solutions for students on limited budgets.

Our institutional course work builds upon the 1-on-1 high-yield tutoring that we do for students individually who reach out to us. The more schools that are willing to partner with us and offer their students our online or in-person Elite USMLE prep course, the more students we are able to help. Building off of our goal to help as many students as possible, we know that particularly for international medical graduates (IMGs) and students from disadvantaged backgrounds, the cost of quality professional medical exam tutoring can often make it inaccessible. In an effort to drive down the cost, we are working to come up with these sort of modular mini courses that will be available throughout the year to students who are seeking help in preparing for their licencing exams.

What are your favorite books, podcasts, or resources that inspire you to be a better healthcare leader? Can you explain why you like them?

My favorite podcast is the Bill Simons podcast which is primarily sports. It allows me to get away from thinking about the day to day, but also it does cover a bit of culture and even recently a bit of politics but largely sort of in a non partisan way. Additionally I like Freakonomics podcast and I also liked the book a lot. The book that I most recently read and really liked was a book called Rage by David Epstein. The book is about how having a variety of experiences can make you stronger in a number of different fields whether it be sports or business or music. The idea is that you don’t need to specialize or super specialize early in life or early in your career in order to get better outcomes. Rather, a generalist, someone who does a variety of different things may end up with a stronger set of outcomes in the long run. It may take them a little bit longer to get to that point, but in the long haul they tend to produce greater outcomes and have better life satisfaction. The book also explains why people who might take delays in their education or their training to do other things that are seemingly unrelated can actually end up producing much stronger abilities in their given field because they are able to bring in outside interests and influences.

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. 🙂

A long term issue that I would like to personally inspire is pushing people to be more environmentally conscious. With the possibility to track over hundreds of years and potential major implications for the existence of mankind, the environment is an issue that I think more people need to be acting on. One of the ways that people can contribute to helping the environment is through changing our consumption habits and specifically what we eat. Human eating habits seem to be a big driver of environmental damage worldwide. Recently, the issue that has captured the most attention for me in the context of reducing human environmental impact is reducing meat consumption. Without going into an in depth explanation, by reducing meat consumption we can reduce our environmental impact, be more ethical, and increase our health. I encourage everyone to read up on the environmental issues facing the world as well as how changing our habits as a society can make a large scale impact.

How can our readers follow you online?

Feel free to follow the Elite Medical Prep blog for USMLE and medical exam related articles, announcements, and study tips. You can also follow us on Twitter, FacebookLinkedIn or Instagram.

For anyone interested in connecting with myself or Dr. Ken Rubin directly, feel free to look us up on LinkedIn. Business inquiries can also be sent to [email protected].

Thank you so much for these insights! This was so inspiring!

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