Naval Flight Surgeon to Family Doc...The Journey of Dr. Otten!

Brian Urban:

Yes, this is the Healthcare Rethink podcast. I'm your host Brian Urban, and we're continuing with our author series here at the Healthcare Rethink. We're so fortunate to have the author of, Ripple of Change joining us today, Dr. Todd Otten. Thank you so much for joining our little show here today, Todd.

Dr. Todd Otten:

Oh, it's wonderful to be here. Thanks for having me.

Brian Urban:

You've been making the rounds with your book the last year plus here, and you've been having a nice voice on different podcasts, so it only made sense to continue with that theme and support the voice and the voices that you have inside of Ripple of Change, which is a fascinating book that was at your time being a burned out physician, having a deep connection with a frustrated patient.

And there's so many other patient stories and fascinating quotes inside your book here. So hopefully there's a follow-up to this book in some fashion, but I won't push you to write anything else yet. But love what I read and want to dive into it. But first, let's get to know Dr. Otten, before you were a naval flight surgeon, before you were a physician executive, before you were a family physician. Let's go back many moons here. How did you find yourself going through this path? Why did you go into medicine in the first place?

Dr. Todd Otten:

Oh yeah, and actually, I'll double click on the book comment first because interestingly enough, I think I've landed on a title for book number two. I won't do spoiler here, but it's going to involve a little ... Okay, we'll just say medicine forward and maybe the power of one plus one. That synergy that I've come to find to be so amazing with my colleagues, when really your hearts are aligned in the right direction.

But to go back to the question, when I was in grade school, I wanted to be all kinds of things, stockbroker, lawyer, engineer. And a lot of it came back to the sciences. And when I was in high school, I was a supervisor at Parks and Recreation. So during the summer you'd watch 80 kids play games with them and all these other things. And I really loved that interaction. I loved that connection. The smiles that would come from it. And so, I started thinking, "Okay. I guess I wasn't thinking back then I'm a type A personality. But I'm probably type A plus in some degree or another. But what blended with science and helping others in that humanity. And so then my mind started going to medicine. So I was probably 16 when I decided I wanted to become a physician and then it was head down, let's make it happen.

Brian Urban:

Wow, that was early on in your youth deciding a very challenging but rewarding path. I'm not sure if you ever thought you'd be an author, but what better way to put your insights to use than putting it into a very deep reading that I think a lot of others have seen and are being able to pull insights and application into their own world. So fascinating. And I wanted to touch on Joshua Judy, who is the patient voice, and really a strong relationship for you in life since meeting Joshua.

And it's interesting. In your reading, I think a very lovely way to open the book, the patient starts his piece first. So Joshua opens up in talking about his journey from a child all the way to an adult. The different technology and physicians that he meets along the way. Not only from primary care but dentistry as well, and talks about all the different changes. Scripts and a co-insurance being maybe $2 at one point or nothing. And his father was an employee at GM in Michigan, and how kind of things were influenced and changed. And he really started to bring some really insightful observations. And then he closes with his first part about when he meets you. And then he was wondering, "Well, how long will it be after I meet my next primary care physician after Todd?" But not the case necessarily. So tell me what that first meeting was like with Joshua, and how this relationship started to unfold throughout the book a little bit more.

Dr. Todd Otten:

Oh, for sure. So I had met Joshua at this point probably close to 15 years ago, and I was new to my then job, if you will. White coat, tie, all that kind of thing, maybe a little bit of nerves at times. And I think as he alluded at one point in the book, I inadvertently semi choked him when I was doing an exam. But we connected right away. And so, we remained in that doctor-patient relationship for the better part of a decade. And it was during that he really struggled with his health. He had cervical radiculopathy, a pinched nerve in his neck, and we tried everything under the sun. Injections and therapy and referrals. And he met all these roadblocks and I won't get into the weeds and go down too many rabbit holes. But ultimately, we had tried a medication for him with just horrendous side effects.

And it got even worse when he tried to come off of it. And that's when our journey together got even more interesting. Because it was at that point that was writing, and it was cathartic for me or the start of some catharsis really from coming out of burnout. And I was looking for ideas for him. The traditional things that we would expect to have worked weren't.

And it was at one of the visits I told him about the project. And at that point I had only written a poem in maybe one chapter. And I said, "Well, hey, are you interested in writing about the quadruple aim?" And he's like, "I don't even know what that is." And so I told him and he's like, "I'm not sure I know what it is now that you told me what it's." But he said, "I'm interested." And I think in part because he believed in me and wanted to support me. And he said, "Well, what should I write?" And I said, "Just write." That's the only instructions I gave him. And it was beautiful. And we had a meeting, and it was after that the trajectory of the book took on a completely different form to what you have in front of you now.

Brian Urban:

I love that because you can't script a patient experience, or stage it out. He simply did just speak his mind. And I think it was very insightful. It came out naturally, at least in that beginning part. And then later on he begins to talk a little bit more about how he believes that you truly came into medicine just to help people, as a baseline piece of the humanity connection that you were talking about earlier.

So I won't go too deep into that because I'm going across the book here in some big chasms. But it's funny you mentioned quadruple aim. That's mentioned quite a bit in the latter part of your book. I remember when it started out as the triple aim, at least from the health plan perspective. And then later the quadruple aim, adding the experience portion of that. And I don't know how well that aim has been executed.

It's spotty and best across the entire ecosystem of U.S. But your experience, let's go there for a moment, with the quadruple aim that carries a lot of weight, I think, into the narration later in the book. Was that something that Joshua gave you insight into maybe how the quadruple aim was being applied to just a general patient experience, and how it's maybe not being met? Did you both talk a lot about that from the high level of what that means in the industry?

Dr. Todd Otten:

For sure, and I've seen the quadruple aim work at the office level, the hospital level, the ACO. And my hope is that we can see it even beyond that. What was fascinating about the process of writing the book with Joshua is he's a night owl and I'm a morning guy. And so, we're working asynchronously on this on Google Docs, and it was this beautiful back and forth conversation about the quadruple aim. And really how it could be extrapolated not just to healthcare, but really just about anywhere if you think about it.

I mean, it's intended to be molded, and malleable. And use it whether you're a teacher, or a physician, or a lawyer, or whatever. But I think the really interesting part of those conversations was how we chose to use the word our in front of it. Because we've gone from the triple aim to the quadruple aim, and really now the quintuple aim, talking about that health equity piece.

And a lot of these conversations are heavy, if you will. And frankly, there's parts of the book that are heavy. And so, we're like, how can we make this simple, actionable so that the average person can take this and run with it? And that's why we chose the word our. So really we feel like our quadruple aim is akin to the quintuple aim. And it's only eight words. Patient experience, quality care, lower cost, provider wellness. I think the vast majority of people can take a component of that and maybe play their part to make this mess that we're all in better. And so, that was kind of the evolution of it.

Brian Urban:

That is really helpful grounding into where I'd like to go next here, Todd, which is there's a lot of serious conversations, anecdotal stories that are dropped in the book on a continual flow. But a theme that I saw was humor. There's a lot of interesting quotes that you have with different sections. And I think a lot of patient quotes that you have in there are really funny as well. One patient said, "An EKG why do I need that? My three ex-wives said, I have no heart."

I think that was ... I saw that and I was like, "That's pretty good." This patient had this in mind maybe going into this appointment. But how important has humor been for you in terms of wellness as a physician, and maybe the patient provider relationship that you've had with many, many lives in many different settings? How important has that been for you?

Dr. Todd Otten:

Oh, critical. Critical. Medicine's tough. And being a physician, there's a lot of telling people they're dying or witnessing people actually die. I can't even tell you how many times I've been in those situations. And we have to have tools in our toolbox to reset, if you will. And so, it was pretty early on in my career that I really started to use humor as a tool.

And in many different layers. I'll use it in podcasts, or if the conversation is going in a wrong direction, and maybe bring some levity in to de-escalate things at times. To me, it was invaluable. And frankly, the further on I got in my career, it was daily. As you read in the book, I can't remember what chapter it's in because time goes by and I've got gray hairs, and it is what it is. But it was daily and we had a blast at work. And patients, you're going to make mistakes. There's going to be errors, and you take it too far. Sometimes you have to apologize and say, "Hey, you know what? I didn't mean it that way and it is what it is," but 99% of the time it played out perfect. The beauty of that is the staff and the patients want to be there in the office. It was just magical when it went well.

Brian Urban:

Well, I can see that coming from your reading because it's very noticeable. I think you don't go maybe more than a few pages throughout the book without seeing something of a humorous nature because it's definitely a part of how you deliver medicine and have a really important patient-provider relationship. So wanted to just call that out for a moment. I think what's really interesting for me, just to back up, there are so many parts of your book that have deep insightful stories. Not just quotes from patients. How did you get all of these patients? How did you curate these stories? This had to be a massive outreach. Or is it just speaking to how good of a physician you are, that good of a relationship manager you are to have these people say, "Yeah, I'll give you some quotes. I'll give you some insights. The good, the bad, and the funny. And the good, the bad, the ugly." So how did you do that? There was a ton of quotes in there.

Dr. Todd Otten:

Well, wow, there's probably a few components to that, at least in regards to maybe the jokes or the humor. That had been developed over years. I started doing that probably 10, 15 years ago, just jotting things down that patients had said. And quite frankly, some of them are not politically correct, and certainly could not make it into a printed form. But I think it was probably a blend of the two parts that you mentioned.

I'd like to think I did the best I could at my job. And I think what people really resonated with is they know that I cared. I loved my job, and I loved seeing patients, and I gave a beep. And people can pick up on that. And when you do that, when you reach out to do these other endeavors, the outpouring was just incredible. I don't know what percentage of individuals contributed that I had asked, but it was high. And it was very rare that someone would say no.

And maybe it was a little, or maybe it was an article they would share with me or whatever. But after a while, once word got out of what I was doing, I was getting stuff from all over the place. And it became like, "Oh my gosh, we can't talk about everything in healthcare, because this would be like a thousand-page book instead of 500 pages." But it was beautiful. And then we sort of over time we massaged those things into, "Okay, where does this piece of the puzzle fit to have a good flow between Joshua and I?" Yeah. So it was just this incredible outpouring of energy, story, and emotions. And then ultimately weaving it together with my co-author.

Brian Urban:

Yeah, I was just fascinated. It was one after another. And it wasn't just filler space. It was very helpful insights that showed what a person was experiencing at that given time, and what was helpful for them, and what they still needed help with. So I want to go back, Todd, actually to the beginning of our little podcast here. I had noted that as a part of your background, you were a naval flight surgeon. So, just had Memorial Day here in terms of our calendar when we're talking.

So I want to thank you for your service and serving those who had served our country as well. So I want to get a take on your experience then and comparing that into maybe a family physician experience that you had a little bit later in your career at a different time. So when you were serving those in the Navy, how complicated was care coordination? I mean, we're going back a little bit here, but is it anything to the degree that physicians struggle with today? Obviously you were in a different system, but can you give me a comparison of your time treating naval force and then also just civilians as well? I was kind of curious of what the two cultures, what the two populations look like.

Dr. Todd Otten:

Yeah, that's a fascinating question. And frankly, I hadn't really considered it that way. When I was a flight surgeon, I often joke it was like being a doctor in a fraternity, but that's probably a different topic for a different time. But the beauty of it was is I was in charge of just about every aspect of the healthcare for those in the squadron. So when we would deploy, I was responsible for everything. And I was in very good communication with my commanding officer, CO and XO, regarding the health and wellbeing of the squadron. Because ultimately our goal was to keep a healthy fit and fighting force, if you will.

The bureaucratic and clerical burdens were significantly less. I didn't have to submit claims. I didn't have to do prior authorizations. I mean, there was different bureaucracy, like the hierarchy of the Navy and all that kind of thing, but I was an N of one.

So when I go to tell my CO something, he's not going to be like, "Well, Doc, I don't agree with your assessment of what's going on with the patient." I mean, why would a pilot do that, right? And I think that's an amazing comparison perhaps to some of the struggles that exist in the commercial space, or the existing landscape, if you will. Think about prior authorizations. I'm the one sitting in front of the patient, I've got all information, there's all this silo data that whoever's reviewing it probably doesn't even have yet. They have the ability to say, "No, you can't do that for your patient." It's crazy. And maybe that's the best comparison between the two. And frankly why my colleagues are so incredibly frustrated when we hear terms like burnout, and moral injury, and unfortunately worse in the existing landscape.

Brian Urban:

And I knew that the administrative burden, the hurdles if you will, were at the base of that. And I am a huge fan of what the VHA has done in recent years, especially regarding addressing social health needs, mental health in particular. And obviously different system, different population for sure. But when you look at what they've been able to archetype, do you feel a lot of that should start to just flow over into the commercial space? And it hasn't for a lot of reasons in terms of private health plans, Blue Cross Blue Shield entities. CMS down to state levels. But here and there we should see things flow over to a health plan to have better coordination, especially if they're an IDN. Do you feel or have you seen a lot of the work that you've done or the models you've been incorporated with when you were serving those in armed forces, starting to flow over to the commercial private side in the U.S.? Or is there still just such a big barrier and it's a completely different landscape?

Dr. Todd Otten:

Well, I think a couple components to this, Brian. I think I actually recently started going to the VA to get some care for a host of reasons. And I got to tell you, it's been fantastic so far. So I totally echo a lot of what you just said in terms of the efforts that have been made within the VA system over the past couple of decades to having a very positive experience personally.

One of the biggest issues I think that we have in the private sector is the lack of aligned incentives, and who are the incentives aligned for? And you really could boil that down really ... And I don't want to oversimplify this, but who are the fiscal incentives aligned for? And in many cases, they're not. Well, actually in most of the cases I would say that they're not. And that's caused a lot of the dysfunction that exists today.

However, there are entities that I would say that the incentives are much more aligned. Maybe it's not perfect, but there are a lot of wonderful organizations out there really trying to move the needle in that regard. Ironically, I started, and I'll give you maybe just a simple example of the work I'm doing now. I took a part-time job with Emergency Care Specialists who is a physician led forward-thinking ER group.

And they're doing some amazing things. And without getting into the weeds, they're already entertaining how can we work on or consider social determinants of health, or maybe social dynamics of health, depending on what circle you're in. How can we incorporate that into our work so we can really get our focus on where it should be, which is people. And as, maybe to coin a phrase, humanistic [inaudible 00:21:17]. He's such a good guy. Anyways, but yeah, so to answer your question, I think there are a lot of groups out there doing it. We just need to continue to connect those dots.

Brian Urban:

Yeah, I love that because I think we do have this big overshadow of things are never going to go toward a pay for performance or truly incentivized payment infrastructure in the U.S. relative to healthcare. There are a lot of entities that are straddling fee for service and pay for performance, and they're trying to do that. But I think, for me, what I'm hearing from you and a lot of other great folks that we have on the show is the difference between the point of care, and what technology is enabling a physician to deliver better care.

So with that thought in mind, in your time across the ecosystem here in serving so many different populations, you've seen a lot of different tech change. Are you looking at some of the failures in maybe retail health relative to standing up primary care through their footprint, Walmart, Walgreens, CVS, folks like that, Amazon? Are you seeing those failures as, "Hey, you're trying to scale a very difficult low-paying portion of healthcare, rather than maybe enabling the physicians to do better?" Are you seeing it like that, or are you seeing that there's too much technology now, it's too much of an overload for physicians?

Dr. Todd Otten:

Well, this could probably go in a couple different directions, I suppose.

Brian Urban:

Loaded question.

Dr. Todd Otten:

Well, yeah, but that's okay. I mean, I think we're trying to build the airplane as we're flying, right? The current infrastructure is a mess, and we don't need to reiterate that. So I love and I encourage all these efforts to find a different model that works, and are we overburdening our clinicians? Without a doubt. And we need to think very differently about how we're doing that. And I won't get into the weeds of the failure of some of these big retail agents. But maybe I'll spend it a little bit and shine a light on something that I do think is working, and I think there's more opportunity going forward. And that's direct primary care or DPC. I think DPC has a lot of value to it. I think it's a fascinating model that reduces and/or eliminates a lot of the administrative waste that exists.

Is it perfect? No, I think there's room for improvement there too, but I do see a lot of potential with that movement. And so, am I discouraged by some of these failures? Maybe, maybe not. At least people are trying things differently as opposed to the status quo. And that's what we've got to do. We have to challenge the status quo. Because somehow we have managed to spend three to four times every other developed nation out there with just horrendous outcomes. So what we're doing clearly is not working. So I applaud efforts that are trying new things. And I recently did a keynote and part of the keynote, I did a failure bow, which I learned from ... Oh boy, I don't want to mess up her last name. Adrienne Basse, I believe is her last name. And maybe we could fix that. But I loved it. I screwed up on stage. And so I literally just did a bow, and everyone laughed and appreciated it. We're human beings for goodness sakes. In the end, we are humans, and we've got to remember that.

Brian Urban:

I love that you said that, Todd, because I think right now big brands are being targeted for how they can do better. And when they fail, they're not really lifted up and saying, "Hey, you failed, but what can the rest of the industry learn from your failure?" It's just looked at as, "Wow, you failed. You couldn't do this. On to the next one. Who else is going to try and fail?" It's kind of a doomsday, Debbie downer look. But I like your perspective of, "Hey, it's an opportunity to learn, pick up and see who can fill in."

So I love that. And I think that speaks to my last question here as we close our conversation out, maybe the first of many, if you're coming out with this other book soon, and we're all excited about that. You had noted during your retirement, I believe later in the book from a smaller office, a family physician at the time. You were noting that the workforce in the office was going to different roles and they were burned out.

You noted nurse practitioners moving into different opportunities and things kind of breaking apart in not a bad way, but just as an inevitable way, I suppose. And my question with kind of your observations then, and maybe into now, are we going to continue to see this change that people are leaving to either do virtual medicine, telemedicine, or be bought up? They're going to go into private practice, to hospital owned, or get out of the industry completely due to burnout? Are we going to keep seeing these radical themes, and having capacity issues with specialists in cancer and primary care, or what's your prediction I guess, around that?

Dr. Todd Otten:

Yeah. Well, first just maybe a short comment on the exodus from the office. Had the quote unquote, "day the music died," had not occurred within the book, I actually think the majority of us would still be there seeing patients. It was magical. The culture was incredible. The turnover was very, very low. But the decision to move the office to save on rent caused a cascade of decisions that occurred. And it was very unfortunate for primarily the patients, but also the system that just lost a bunch of good human beings to be quite fair. But to come back to the question, we are at a very concerning time in our healthcare landscape. We cannot have 40-something physicians who should be in the prime of their career walking away because they're so frustrated. And there are many. There are many. There are many, many, many. Someone who's been trained for a decade to get so frustrated with what's going on and walk away, that is a huge, huge red flag.

So unless things dramatically change, I am concerned that the shortages that exist, not just for physicians but for nursing and all these other frontline healthcare workers will continue. We need to see dramatic changes, which is why I suggest repetitively to challenge the status quo. However, I want to end at a positive note and maybe share something, a project that is being worked on called Prescribe Hope.

Prescribe Hope is an audio documentary that is really going to rip the Band-Aid off the mental health decay, the depression, the moral injury, the burnout, the suicide rates, on all these clinicians top to bottom. But we're not just going to talk about it. We're building towards activation. We want to mirror the safe haven work that's been done in Virginia by the Medical Society of Virginia, and shout out to Melina Davis who's a friend. We want to get that in all 50 states. And if that can happen, that will be huge. That will impact millions of people in a positive way, which could stem the tide of this exodus that we talked about.

Brian Urban:

I love it. Prescribe Hope. And I'm assuming our audience can find more information with a simple Google search of Prescribe Hope. Or is there a certain site or link that anyone could go to?

Dr. Todd Otten:

Yes, I should know this off the top of my head, but we have a [inaudible 00:29:15] link with Prescribe Hope. But if you look me up on LinkedIn, I've got posts all over the place. And if you go to Medicine Forward's website, medicineforward.org, there is a link there. We would love your support. And actually, I'll maybe double click on this, Brian. Sorry. One of the things I tell people is it's time, talent, or treasure, right? Not everybody has the capacity to write a book, or be on podcasts, or whatever. Or say you're a patient and you want to make a difference, go to a project like this and donate five bucks. All the money is going to go towards these projects to try and make things better for everyone. So with that I'll [inaudible 00:29:57]

Brian Urban:

I love it. Dr. Todd, I think that's amazing. We'll put the links in here. They should be visible for our audience in our video content portion of this podcast. And to your point, everyone needs to make a contribution, and this is one of those great examples of it. So Dr. Todd Otten, Ripple of Change. One of the great authors of this book and an author to be, again, with a future book that you tease our audience with here today. Thank you so much for joining our little show.

Dr. Todd Otten:

My pleasure. Thank you for having me.

Brian Urban:

And for more exciting insights and excerpts, please visit us at finthrive.com