Chapter 9— e Provider’s Responsibility

Chapter 9 The Provider’s Responsibility

So far, I have described ways the healthcare system has impacted providers and have given some simple and inexpensive changes that could restore provider ful llment and excitement. While the system, along with regulations and payment schemes, has undoubtedly made our lives less enjoyable, we are not exempt from blame for the current situation. In my experience, providers have abdicated their responsibility in many situations. We are, a er all, central to healthcare delivery and not helpless or powerless to promote change! In some cases, we have abused the system to our advantage; in others, we have become egocentric and entitled.

To be respected as part of a solution to the dysfunction in healthcare, we must set the example and take responsibility. Four key character traits are fundamental to providers being empowered to improve the system: humility, accountability, integrity, and leadership. I believe it is important to discuss these and to own our part in the current dysfunction. Before I get into these topics, and to help you understand the basis for my perspective, let me share my story with you.

My Story

Where I was born doesn’t exist anymore. In 1953, my father, Jack, was deployed with Naval Intelligence in Alaska. I’m not sure he was in one of those if-I-told-you-I’d-have-to-kill-you jobs, but it was enough to keep him on station when I was born at the North Island Naval

Hospital in Coronado, California. ankfully, although the hospital has long since been demolished, the famed Hotel Coronado still reminds me of those earliest days of learning to walk in the breezy sun of Southern California! We moved o en during my childhood due to my father striving for higher education in New York City, student teaching, and then securing his big opportunity as a school principal in upstate New York. My brother (three years junior) was born, and we were by all accounts a typical postwar family of the 1950s. en, in the summer of 1960, my path into medicine was abruptly placed before me. My father died quite quickly from Hodgkin’s Lymphoma at the age of thirty. As a seven-year-old, I became the man of the house. I distinctly remember the surgeon general’s warning in 1963 that smoking caused cancer. at was when I determined (unconsciously at rst) to stamp out disease.

With both parents being educators and having a librarian for a grandmother, I found it easy to devote myself to my studies, and I was fortunate to ultimately nish medical school in 1978. is was during the dawn of the subspecialty we now call interventional cardiology. I was drawn to the combination of technical/surgical skills and medicine/physiology needed to perform balloon angioplasty and care for acute myocardial infarction patients.

I was also drawn to a beautiful, life- lled young nursing student named Dinah. She was a senior in the three-year, hospital-based program run by the hospital where I was training. We met in a psychology therapy group for nursing and To be respected as part medical students and have shared of a solution to the the rest of our story together. She dysfunction in healthcare, largely raised our three wonderful children and has supported me in we must set the example my career climb—the many moves and take responsibility. (about een), the frequent travel, and the late nights on call. She has since become an ordained pastor, counselor, and writer. And now she is

nishing her PhD! She has been critical to me, my career, our children, and our shared adventures.

My career has not been static—anything but! I have been driven by the deep-seated notion instilled as a seven-year-old to make a di erence in the health of my patients (a er all, I couldn’t with my father). Being driven can be good, but it can also be overwhelming at times. Learning to balance the drive with compassion, listening skills, and relationships has been a lifelong exercise, one I have failed at frequently. At each stage in my career, I have tried to extract the best lessons and build forward on them. I have also pursued my goals in four seemingly unrelated spheres of life: interventional cardiology, professional education, health-related missions, and entrepreneurship. Each sphere has taught me important lessons, and each has informed my thinking and opinions on the topics in this book. ey are so intertwined that trying to separate them is futile and frankly serves no purpose.

Let me touch on a few highlights of the journey. A er fellowship, my rst o cial job was in the VA healthcare system. I had an encouraging mentor who fostered my desire to study physiology and provided the time and tools to allow me to set up an experimental lab. During those four years, I also began working with industry partners to develop tools needed for the new eld of interventional cardiology. I was fortunate to be among the rst to develop and use intravascular ultrasound in patients, allowing detailed views of the inside of blood vessels. is ultimately led to many publications, worldwide travel, and presentations. At his request, I followed my mentor to my next academic job in Cleveland, Ohio. ere I developed training programs, continued my experimental and human investigation, and supervised a team of nurses, technicians, and trainees. I assisted in the design of a new hospital and helped develop a robust clinical trials operation. Our family spent a year on sabbatical in the Black Forest of Germany. In Germany, I experienced a very di erent style of medicine, one that was more relaxed but also incredibly e cient, more focused on relationships, yet quite productive. It was there that I learned that clinical excellence and authentic relationships could coexist!

A er returning to Cleveland, I assisted a colleague in building a large cardiology program at a tertiary care county hospital. I was subsequently o ered the chance to start a heart and vascular institute at a large community hospital in another city. Unfortunately, I learned that the academic-employed model I enjoyed was not appreciated by all my peers. Our e ort to develop the institute was sincere but ultimately unsuccessful. Wanting to allow my daughter to nish high school in that city, I started a concierge cardiology practice. e recession of 2008 was not an opportune time to do so! As you might imagine, with incomes falling and house foreclosures the norm, patients were not eager to sign up. So we toughed it out for two years, then returned to the East Coast academic environment. I was o ered the cardiology chairmanship at a large integrated health system. While not university a liated, it was academically oriented. I learned about the incredible advantages that can be realized by in uencing all three parts of the healthcare system: provider practice, hospital services, and insurance.

Ultimately, Dinah and I moved back to the Cleveland area to be near our children. I was able to work in the same academic center I had le een years prior. I have also been able to work for an organization that provides cardiology services for smaller hospitals that cannot support hiring multiple physicians to provide interventional services. From foreign to domestic, rural to urban, not-for-pro t to for-pro t, community to academic, and small to large, I have experienced the gamut of health systems. I have tried to be a good student and learn ways to improve the system from each experience.

When not at work, we participated in medical mission trips as a family. My wife and I felt it important to expose our kids to the “real world” outside the United States. In the early 1990s, my daughter (who was eighteen months old) slept in a suitcase and a backpack while my wife ran triage in a small mountain town in Honduras. My ve-yearold son entertained the local children and escorted patients from triage to the exam area. My eight-year-old son helped in the “pharmacy” packaging meds into baggies for the patients. I worked with an interpreter and a dentist to deliver whatever care we could manage. Trips to Haiti,

Nigeria, Ghana, Benin, South Africa, Swaziland, ailand, Peru, and Russia followed over the years. By the time they graduated from high school, my children had been in over thirty countries. Most importantly, these trips kept us humbly aware of the incredible healthcare opportunities we have in the United States.

My educational e orts grew into several small companies developing educational so ware for healthcare professionals. With an engineering colleague, we developed image interpretation so ware. With another very talented programmer, we wrote award-winning interactive training programs using the internet in the days before smartphones and apps. Our mission work grew into board positions with several organizations and multimillion-dollar Centers for Disease Control and Prevention grants to promote childhood health in sub-Saharan Africa and India. My clinical and academic experiences led to wonderful friendships with medical leaders around the world and in uential positions on writing groups and with professional societies. My time training cardiologists worldwide in interventional techniques again exposed me to a wide range of healthcare systems in foreign countries spanning Europe, the Middle East, India, South America, and Asia.

I have one younger (and smarter) brother who has been involved in private equity investing since 1982. Fi een years ago, I convinced my brother that we should be investing in start-up companies in the healthcare space. I looked for interesting ideas, and he provided the business acumen. We have had some minor successes but many more failures! I have seen what works, what does not, and how hard it is to get even great ideas through the maze of regulatory and marketing hurdles to successful commercialization. I also have learned that regardless of how novel or exciting the technology may be, creating a successful company depends far more on the leadership guiding the e ort. Leadership skills are key, not only in business but in healthcare. at important topic will be our focus in chapter 13.

I mention these varied experiences not as a measure of accomplishment. In truth, some of these e orts and experiences did not

end as hoped, and some failed miserably. I o er them as evidence of a persistent desire to understand how we can provide an environment that combines clinical excellence, business acumen, and compassion. One that any of us would be proud to be a liated with, care for our patients in, and not be concerned to recommend for our own families. I hope that my experiences garnered from varied institutions, spheres of life, and the global community can shed light on the current healthcare situation and empower each of us to make a di erence. If you are reading this as a healthcare provider, many of you have similar stories. All of you are dedicated and hard working. We all have high-functioning capacity, so I know we can create a better environment. We can recapture the missional culture of healthcare delivery. It is our responsibility to do so!