Lisa Farren (Host): Hello everyone and welcome to Crushing Healthcare, where we explore diverse perspectives regarding the state of healthcare today and gutsy visions for a more affordable, accessible, equitable, and sustainable healthcare model. My name is Lisa Farren. For those new to Crushing Healthcare welcome, and for those returning, welcome back.

I'm excited to chat with today's guests. It's going to be a really great discussion. We have a returning guest, Jim Uberti MD is a recognized leader and advocate for value-based care, and we have talked with him about this topic in previous episodes. Dr. Uberti serves as Board Chair at Southern New England Healthcare, which is commonly known as SoNE Health.

SoNE Health is a high value health network owned and governed by independent community physicians. In addition to his work on the board, Dr. Uberti is Medical Director at SoNE Health, where he works closely with SoNE providers to maximize performance improvement and optimize clinical outcomes. He also leads SoNE's network development initiatives. His career as a primary care internist spans more than 30 years with experience practicing medicine as both a physician employed in a hospital system, as well as an independent physician.

And we have a new guest today. We have Kris Gorman. Kris is Vice President of Physician Services at SoNE Health. Her professional career has centered around building healthcare practices that support the necessary transition to value-based care and the quadruple aim, which is to improve the patient experience, improve patient health, reduce healthcare costs, and improve the work life balance for healthcare clinicians and staff. Kris believes the patient-physician relationship is critical to achieving these outcomes and understands that success requires a collaborative, team-oriented approach that's a shared vision, aligned goals, and reliable resources.

So thank you, Dr. Uberti and Kris for joining us today. Welcome. As I was just reading about your professional experiences, I couldn't help but think. Wow, what a perfect segue for today's episode. We're going to talk about elevating and protecting the patient-physician relationship, and why that's so very important today, probably more than ever. On the surface, I think people might think to themselves, okay, yeah, it makes sense. There should be a relationship between the patient and physician.

I also think people may be shortsighted in understanding the many levels of this important relationship. So I think there's a lot to unpack. And let's get started. So to kick things off, let's start by framing things in the context of the current state of healthcare. Dr. Uberti, what is your perspective on the patient-provider relationship? What have you personally seen and experienced?

James Uberti, MD, MPH: Well, a lot of people think currently the healthcare system is broken. That may be an over read, but certainly it's damaged. And one thing that has been damaged is the physician-patient relationship over time. And a lot of that is because of what is occurring with physicians. And I'm using the term physicians, but I'm really referencing all providers now who deliver frontline healthcare delivery. So that would include, for example, PAs and APRNs, who do primary care. There have been a number of surveys dating back over 10 years ago that highlight that physicians are burning out, and burnout is usually described as a syndrome of exhaustion, cynicism, and a sense of decreased effectiveness at work.

Some surveys will report that over 40 to 50% of physicians surveyed have at least one symptom of burnout. Now, those are non-specific symptoms and so that may be an over-exaggeration. However, physicians as a group, tend to not want to report frailty. Some also may be an underreporting.

In any case, burnout is primarily driven by increased workload, increased clerical burdens. During this time period, EMRs have come to the forefront. EMRs, while they're great for documenting, really distract from the meaningful interactions a physician could have with a patient. And there's estimations that for every hour spent in patient care, there's now roughly two hours on the backend after hours and nights, on weekends, on vacations, doing the clerical work.

 There's of course, increased regulatory requirements, which we would all guess become an increasing burden. There's a loss of control over their work and there's difficulty especially due to the workload of work life integration. And so there's just been a steady erosion of the meaning of work for physicians.

The burnout has led to a lot of physicians, especially frontline doctors, like emergency room physicians and primary care physicians leaving early, retiring early. They have lost a lot of that sense of satisfaction in their work. So we have a lot of good, experienced doctors, don't really want to put up with things as they are and are departing the profession.

I'm also concerned that there's also a cohort of younger doctors now who don't see their work in the passionate ways that maybe some of the older physicians did, and they view it as more of a means to a good paycheck and a convenient lifestyle, rather than the joy of going the extra mile for their patients.

So in any case, burnout translates and impacts every aspect of healthcare, both from the number of physicians leaving and therefore patient access and also to patient satisfaction in the care they received as they're much more limited in the time they get to spend with their physicians.

Host: So with less time, it makes sense that the relationship erodes between a physician and the patient because relationships take time.

James Uberti, MD, MPH: No doubt.

Host: Kris, do you have anything to add to that?

Kris Gorman, MBA, RD: Yeah, Jim certainly hit on a lot of the aspects of the increasing burden and burnout on the provider side of the business. I think in order to rebuild trust and focus on the patient-provider relationship, organizations really need to create an, an environment that allows providers to work at the top of their license and skill.

And having worked in healthcare since, geez, 1997, I've seen a lot of change and I've always been part of teams that has really worked to create the capacity of, of the providers so that they can really meet the needs of each patient. Each patient has such individual needs. So I think really looking to specifically hire the right support staff to surround the providers.

And then of course to consider efficient technology that can also support the providers in order to have that time to be able to spend with the patients, to really understand all of their health issues, their barriers to improving health and really having the opportunity to create a custom, very specific, individualized solution for the patients in order to improve their health or to treat their illness.

So making sure that we're really hiring the right people and that we have the right positions to be able to support the providers in the care that they're providing to patients. I think that's critical. And also looking at ways that we can reduce the administrative burden on our providers. So through technology, even, you know, something like an AI scribe, a virtual scribe, or a physical scribe, making sure that the electronic medical record systems that we have in place are designed to really meet the needs of the individual physicians and providers. Each specialty's kind of different. So making sure that they're really customized to, to handle the workflows so that the providers can move through those necessary documentation pieces as efficiently as possible. And also making sure that the technologies are communicating from specialists to hospital to care provider as efficiently as possible so that that interchange of communications and care plans around the patient's needs and health can be communicated as efficiently as possible.

And also thinking about the administrative burdens associated with some of the hoops that we need to jump through for authorizations and those sorts of things with the insurance companies. So just making sure that we have the systems in place to really reduce the burden for the providers so that they really have the time to spend with the patients.

Host: Great. So when you're speaking of technology and other tools to help ease the burden, and then you mentioned, allowing the providers to work at the top of their license. So are you referring to allowing like a team-based approach, in other words, is what I'm hearing within the practice?

Kris Gorman, MBA, RD: Yes, exactly. Lisa, I think the providers need to be the captain of the team.

Host: I like that.

Kris Gorman, MBA, RD: The captain of the team. They absolutely have to be surrounded by the right players, and they need to have the understanding and desire and the time to be able to kind of captain their teams, but also captain their patient care.

Host: That's great. So with that, in an optimal situation, as you described it, it sounds like it allows then the provider to have the autonomy, the freedom to really spend time with what they went to school for, essentially is patient care. Right. They're not worrying about all that other necessary stuff that has to happen, but that's not what, that's not the goal for them.

And autonomy is important for both patients, I would think for doctors and patients as well. So, but I think in the way you described it too often, the way healthcare is modeled today, our models don't encourage autonomy. So Dr. Uberti, I'm going to look to you again. As a physician, how do you define autonomy?

 How common or elusive is it in healthcare today? Why is it important? Do you see it? How does it fit into the big picture?

James Uberti, MD, MPH: I, I'm glad that you brought that up because really it's the loss of physician and patient autonomy that has led to dissatisfaction amongst both. If we look at physician autonomy in the broadest sense, it's really the freedom and control physicians have over their clinical decisions, the settings they practice in, the professional activities they engage in and really just ensuring that they can provide the best possible care based on their expertise and judgment. More simply, it's providing care in the way that we envision when we entered the profession. Time to spend with patients. And time to listen.

If we go back to the 19th century and look at a quote by Sir William Osler, who was actually one of the founder of Johns Hopkins Hospital down in Baltimore. He made the uh, statement, listen to your patient. He is telling you the diagnosis. And really from the time we're in medical school, we learned that, you know, over 90% of our diagnoses are made from the history.

And that's just from talking to your patient, from listening to your patient. So when we look at, patient autonomy it's really the right of a patient to make informed decisions about their own healthcare. And it's really getting them to, they would like to participate actively in their medical care, be part of the team that decides what care they should get, how it should be delivered, et cetera. Well, that all comes back down to the essence of listening. So physicians really just want time to listen to their patients, and patients want the time to be listened to by their physicians.

Host: That sounds idyllic. Absolutely. Kris, what have you seen in your work around this topic?

Kris Gorman, MBA, RD: Well, I think, the perspective that I always take is, first through the lens of a healthcare consumer. And by that, I mean a patient. You know, I'm a patient, so, kind of looking at from an administrative perspective, how best administrators can support the providers to meet the needs of patients is incredibly important.

We really have to understand what the needs of the patients are. I think autonomy, for providers looks a lot like creating agency, which then leads to fulfillment in the work that they're doing. For patients, I think autonomy is the ability to be able to choose the providers that they're seeing, to be engaged in their healthcare, to have the time with providers, to really learn and be educated on their health conditions and to be able to make changes in their lifestyles to be able to prevent illness. So I think it is my responsibility as a healthcare administrator to live through that lens in order to make sure that I'm working alongside of providers like Dr. Uberti to design an operational system and the necessary resources to make sure that the providers have the ability to take the time to build the engagement that's needed in order for patients to really have their needs met.

So, I think that's a challenge. And one that I, take very seriously and I'm proud to be here and having this conversation because I think the more that we talk about this particular topic and the autonomy of providers and patients and really focusing on that relationship, the more transformative all of us will be. We'll start to expand our thought process and really refocus on that particular relationship. I believe that relationship is what will drive the care for our patients.

James Uberti, MD, MPH: What's very interesting, Lisa, is that when we look at autonomy, it's the smaller, independent practices, which you think have a lot of burdens on them because they have to keep their doors open and it's hard running a small business, which is essentially what they are.

But they also have greater autonomy versus, when physician in an employed model and they have less burnout. When you look at the statistics, much less actually, and it probably goes back to autonomy. They have more control over what they do and who they see and when they see the patients, and the ability to spend time in the examination room with those patients.

So it, again, the optimal physician-patient relationship comes when both physician and patient approach each other with mutual trust and respect. And that relationship is really developed and nurtured by time, by having the ability to spend time with the patient.

Host: Again, it sounds idyllic. It really does. It's a lot of orchestration. It sounds behind the scenes, which ultimately gets to a place where both the doctor and the patient, they're both on the positive trajectory. They're building trust, they're working collaboratively, partners in care, which I know that's sort of a catchphrase now, but it sounds like that's really what it is.

 And there are things that can be done and tools in place as you described Kris to help support that and reestablish it. It kind of makes me think back to like the Marcus Welby days actually is kind of what I was picturing while you were both talking. Because I think nowadays, oftentimes when people think of, at least I do, when I think of appointments, being in the room with a physician, it all feels so rushed.

It's like, can I, how fast can I talk to make sure I get all my questions answered? And I think that it comes down to, like you said, time. Time is what's critical and the support around the physician in the practice so that they can put the patient first and the patient is really at the center. And I would think that ultimately would lead to better outcomes as well, correct?

Kris Gorman, MBA, RD: Agree. Yeah, Lisa, I just have one more point actually. It's more than the operational support that's needed to create the autonomy and improve the outcomes for the patients. It also requires the organization to have the right governance structure. So operations obviously is what helps to provide the efficiency and make sure that the right staff are in place to support the provider.

But making sure that the organization has a governance structure that supports the opinions and the clinical needs and the voice of the provider in making all of the decisions within the organization and having a collaborative arrangement really between the administrative operational team and the clinical team so that there's no side wins.

Both sides need to really accomplish their goals. There are no sides. It's one team, one system being championed by the provider and really with the administrative team and the operational support to create a sustainable system around what the providers need. So I just wanted to make sure I pointed out how important the governance structure is.

James Uberti, MD, MPH: I think that's very well said, Kris, because I, I think in any organization, especially in the complexities of today, sorry, Lisa, we're not going to have Marcus Welby coming through that door, holding his bag, making house calls anymore. However, even given the complexity of today's healthcare system and the payer arrangements and, all of that, I think if an any organization and their governance, maintains a focus on patient-centeredness; the patient being the center of all that we do. And also, if that organization honors the sanctity of the physician-patient relationship, then they will at least be headed in the right direction. And so that can occur in an independent model where we support the independent practices and do everything we can to ease their administrative burden so they can spend time with patients.

Or even an employed model where we can en, we can endorse and promote team-based care with every member of the team, you know, practicing at the highest level of their license as Kris described, because we talk now that, that's viewed as advanced primary care. I don't look at it as advanced. It's really the essence of primary care.

Host: So hearing you talk, I'm thinking, so the average person who's listening, they might be thinking, okay, I, I'm going to see my doctor next week, for example. What does this ideal care model look like from a patient perspective? What can they look for or do when they're talking to their doctor to see that maybe the physician or the practice they're at is actually approaching their care with this sort of team approach?

James Uberti, MD, MPH: I think I can answer that. So, the interaction with the patient starts with the phone being answered by a member of the staff. Is the patient treated with respect? Are their concerns addressed? Is empathy shown? Are they given an appointment in a timely fashion for whatever level of concern that they have, even if it's just a preventive type of visit? And from the time they enter the office, is the vibe, if you will, in the office, is it one of a sense of collaboration? Again, a sense of empathy and compassion.

When they enter an examination room, does a physician or any provider enter the room and not appear to be rushed? Do they take time to have a meaningful interaction with a patient? Are they listening with curiosity and honesty and demonstrating that the patient is a partner with them in their care?

 These are all things that enhance the patient experience, make the patient more likely to feel comfortable and talk about their concerns, talk about their needs, and guess what, that leads to better diagnostic acumen and better utilization of other adjuvant testing.

Host: Well said. You paint a good picture. So, Kris, in your experience with your background in building different practices, can you talk a bit about how an organization can build this type of model?

Kris Gorman, MBA, RD: Yes, absolutely. It really starts with the governance structure. Making sure that all of the stakeholders' needs are understood, making sure that the providers are at the forefront of working through the different challenges and needs of the medical group, which ultimately, are the needs of the business and the patients, so that we can have a sustainable environment. So it starts with a governance structure, but it also requires a strong mission, vision, and values. I really believe in focusing on a mission that focuses on the patients, the provider's experience, kind of that quadruple aim that you mentioned Lisa earlier.

It's incredibly important that you're focusing on the mission. The vision's important to consider, but focusing on the mission and then the values associated with achieving the mission are critical because everything that you do when you've, when you have a mission and values assigned, needs to align with those statements to make sure that you really are achieving the goals that you've set out to achieve. So, governance, mission, vision, values, very, very important. Making sure that you're hiring the right staff that share in those, in the mission and the values. Also very, very important. Making sure that the providers understand that they are the captains of the team.

And sometimes you have to, you know, all captains need coaches, so sometimes there needs to be a coach in place to help, to really drive the effectiveness of the captain with the team. And then of course, the team needs to be coached to make sure that the handoffs are happening properly.

That the team members are, you know, appropriately kind of viewing the core and understanding maybe what needs to be done for the patient in order to be able to achieve the best outcome. So really aligning a full scope or really a breadth of providers is incredibly important.

So what I mean by providers, and I should, kind of rephrase that, is making sure that the providers have a full suite of clinicians to support them. So pharmacist, making sure there's appropriate nursing staff for care management and the care of the patient from a nursing perspective, dieticians, social workers, behavioral health and community workers, making sure we have the right medical assistants in place. And then to Jim's point, making sure that you know all the way to the patient care representatives that are answering the phones and really seeing the patient when they first walk into the medical office, making sure that everybody understands what the mission and the values of the organization are and that it is to support the patient and provider relationship.

Because we know that's what improves patient care.

James Uberti, MD, MPH: That's absolutely critical Kris. I completely agree. I think if every member of the team, as we describe it, really feels that they're part of a team. It really goes a long way to engendering that kind of collaborative office environment that we're trying to promote. And I think, you know, on the compensation side, we have to think about that because these are all occupations for people from the physicians on down to the medical assistants. We're in a value-based world. That's what SoNE does. So for our independent providers, they can receive rewards for performing well in value-based areas of medicine, and achieving key metrics that we know improve patient outcomes.

Same thing on the employment side. If a physician is employed in a SoNE health medical group, for example, that Kris oversees, we've really worked hard to move away from the patient churning model of just seeing as many patients as you possibly can in a given day, which we don't, which we believe is not satisfying for either the physician or their patients.

And moving to a model where value is rewarded. Patient satisfaction scores are rewarded. I think in the long run, that is the only way we'll begin to repair what we described at the onset of this discussion as a broken or at least wounded healthcare system. And, I have to say that physicians sometimes get viewed as well, you know, they make great salaries and all that and certainly it's a comfortable living.

But I think intrinsic motivators, such as autonomy, mastery and purpose; that's probably more powerful motivator for physicians than extrinsic motivators, such as salary. And that is really what you see associated with higher professional satisfaction, lower burnout, and therefore the development of better physician-patient relationships.

Host: That's nicely said. So, a lot of the satisfaction that they're getting is from the impact that they're having. It's not necessarily the compensation. I like that. What I particularly like of what you both said is what you've described, it's positive, it's hopeful, and it's proactive as compared to being reactive for both the patient and the doctor.

It elevates both of the individuals. It's a real win-win. So I think that's positive and something we can all wrap our minds around. So, is there anything else you want to add? I feel like we've covered a lot. It's all very positive. You mentioned um, SoNE Health Medical Group. Is there anything in particular, Kris, that you want to add that SoNE Health Medical Group is doing to really sanctify and protect the relationship between the provider and the patient?

Kris Gorman, MBA, RD: Yes, absolutely. Everything that the SoNE Health Medical Group is doing, I believe is focused on the patient-provider relationship. Dr. Uberti and I are in a dyad leadership structure where he and I work very closely together on the clinical and administrative needs of the organization to make sure that we're aligned and always putting the patient-provider relationship at the center of the decisions that we're making.

Whether it's, you know, around a staffing model, a physical plant location or technology that we're making recommendations about putting into place. We want to make sure that every decision that we're making is supporting the patient provider relationship and not just adding unnecessary hurdles, steps or barriers.

So we really want to make sure that we're focused on that. I think the governance structure that we have at SoNE Health Medical Group positions us very, very well. So it is a physician led, provider led organization. We have a board that supports everything that the medical practice does. We have very structured board cycle, board meetings and board voting.

And I think that's critical to how we're making decisions within the organization. So administratively making recommendations and operationally making recommendations back to the board and the physician provider board members are really leading all of the decisions that we're making at the medical group from operations to compensation, it really ranges across the entire organization with the mission in mind.

And we start every board meeting with our mission and values in mind that focusing on patient, on the patient-provider relationship is, is really what we have to think about in every decision that we're making. So I hope that answered your question, Lisa. It's living the mission is not an easy task.

Being transformative in healthcare requires a lot of open-mindedness. It also requires a strong commitment. I do think the dyad commitment is essential. I think the governance structure, again, that we have in place is essential to our success. I think it, patience is also critical, meaning our patience in the process and making through, making it through the different decisions that we have to make.

 I hope that answers your question.

Host: It does. Thank you. and kudos. I think impressive to hear as, you're looking at the med group, you really are taking a 360 degree view. Like you're in every aspect, how is the patient-provider relationship going to be supported in every aspect. So I think that's impressive.

James Uberti, MD, MPH: Lisa, the last thing I'll have to say is, and you hopefully recall this from a podcast we did months ago, is that I said at the time that, SoNE Health was looking to take the triple aim now essentially the quadruple aim, from the aspirational to the operational. Well, that's what we've been doing and that's what you'll continue to do.

Host: Nice. Well done. Wow. All right. Thank you both. I think conversations about our healthcare system today often lean in the direction of complaining, lamenting, making people feel kind of helpless. But today's conversation was so far from that. Instead what you've described really offers solutions and optimism.

Really at the root of it all it sounds like is a strong trusting and collaborative relationship between both patients and their providers. It really sounds kind of simple, but as you said it's transformational. So well said, and I love ending on a positive note. So let's end with that, unless you have anything else to add.

 Thank you both, Dr. Uberti and Kris for sharing your time, your thoughts and your expertise today. You painted a really great picture. This is a topic that I definitely want us to explore further. So maybe we'll have you both back to talk more about this. So thank you again, both. I also want to thank our listeners for taking the time to listen in.

Until next time, let's all remember that we have a role to play in healthcare transformation, so join us in Crushing Healthcare.