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Becker’s Healthcare Podcast
Michael S. Smith, MD, MBA, Associate System Chief of Gastroenterology for Clinical Operations and Strategic Planning at The Mount Sinai Health System and Associate Professor of Medicine at the Icahn School of Medicine at Mount Sinai
00:22:25
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- [00:00]
A
This is Scott Becker with the Becker Healthcare Podcast. I am thrilled today to be joined by a brilliant physician leader. We're joined today by a gastroenterologist and a true leader, Dr. Michael Smith. And Dr. Smith is both a doctor. He's also an MBA. He's the associate system chief of gastroenterology for the Mount Sinai Health System, which, of course, Mount Sinai is one of the most respected systems in the world. He also is an associate professor of medicine at the Icahn School of Medicine at Mount Sinai. Just a tremendous career. He's also served as chief of gastrology at different cell systems or hospitals with them outside the system. Dr. Smith, before I go any further, let me ask you to take a moment and introduce yourself and tell the audience a little bit about yourself and about Mount Sinai. Great.
- [00:51]
B
Scott, thanks so much for having me and it's great to be here with you today. I as you said, I'm the associate system chief of gastroenterology for the Mount Sinai Health System, which includes seven hospitals and provides care at over 400 sites, including several ambulatory surgical centers and endoscopy centers that has nearly 50,000 employees, including over 9,000 physicians. It was formed really through a series of acquisitions, first with the acquisition of what's now Mount Sinai Queens by the Mount Sinai Hospital. And then about a dozen years ago, Mount Sinai acquired Continuum Health Partners, which had a series of hospitals and care sites and subsequently added in South Nassau Communities Hospital, now known as Mount Sinai South Nassau. So there are now these seven hospitals and all of these care sites really across the five boroughs of New York City and up into Westchester county and into Long island and within Mount Sinai, there are about 100 or so employed GIS across the five boroughs, Westchester and Long island, and many voluntary and associated faculty in gastroenterology and hepatology as well. I'm really focused today on GI, because that's where I am. But we do have partners who work with us in liver disease and in liver transplant. Our GI core is located in Manhattan where we have two fellowship training programs with around 10 or more new trainees coming in each year to be trained in categorical gastroenterology and hepatology and advanced endoscopy and liver transplant. Our research mission is focused in Manhattan as well, with NIH funded and research that's supported through other foundations and sources. So it's really a true academic hub as well as a patient care hub. But we really have been working very hard with the development of the system to help GI to work More, more as a system instead of a bunch of different fiefdoms. And that is why I was asked to come into this role about two and a half years ago. And what I've been working really hard on with my colleagues across GI and across the Department of Medicine and the whole health system in this role, literally.
- [02:52]
A
Fantastic. And take a moment, Dr. Smith, and sort of, what trends are you watching in GI right now in gastroenterology or more broadly in healthcare currently?
- [03:03]
B
Yeah, the real big thing that has monopolized our time has been the issue of a real sea change in how patients view their appointments and their commitment to their physicians and to their planned healthcare touches. Specifically, coming out of COVID it seems like we are really dealing with an epidemic of what we're calling late cancellations. Patients who have appointments, particularly for procedures, elective procedures especially, who are are canceling those procedures within the window where in the setting of the need to spend longer and longer getting insurance authorizations or to get new patients to fill the slots, we're really in the window where it's too late to put someone else into the same spot. But that becomes a lost opportunity both to provide the patient care, but also to collect on the revenue and reimbursement that comes with it. And as I've gone across the country speaking with colleagues, this really seems to be the single greatest concern across specifically academic medical centers. But I think in general, even in our private practice based ambulatory endoscopy centers, we're seeing this as well. And so I would argue that right now for us, that has been the laser focused, number one priority to see how we can address that and maintain full schedules. In the era of a changing perception of these appointments, I would say that reimbursement is always on the list. And I think no matter what year you would record this podcast, that would be an issue there. Right. We're seeing ASC reimbursement go down. The endoscopy reimbursement in the hospitals is up slightly, but it's not really keeping pace potentially with the costs, the uncertainty of where things are going with telehealth, which many of us have pivoted to in very significant ways in the setting of the COVID 19 pandemic. And afterwards, patients certainly seem to love it, especially our patients who are older, more infirmed, and can't necessarily travel to the route to the offices as easily. And seeing that, you know, these folks really want it, but the reimbursement may not be there. And that uncertainty each time we come to a budget impasse is certainly something that we've been trying to figure out how to deal with that. And you know, certainly in Manhattan, where space is extremely efficient, expensive, the efficiency of doing things by telehealth allows us to use our limited space resources and our square footage for other revenue generating opportunities and other activities that the health system and our GI division needs to deal with. And so certainly that's something that we're working on. The role of data and analytics and optimizing workflows and scheduling mechanisms has certainly been something that we see as increasingly important in terms of what's driving things and also interacting with our C suite and our leadership team. From the health system perspective, getting ourselves on the same page, having good and actionable data is really, really important. I think there are a lot of different mechanisms by which we generate data right now, but knowing what data is good and reliable and actionable is something that's very important as the amount of data that you're trying to consume goes up. I would say patient experience is a really important thing as well. Especially right now. Patients are demanding timely communication, even in off hours, nights and weekends. And how do we maintain a high level of patient satisfaction, especially in New York, where reviews and reputation are absolutely critical to our success as an institution. It affects our payer mix. How do we keep our providers, quite frankly, sane and happy in their role so that they're not looking to go elsewhere? It's very expensive to maintain 247 communication with patients with a live person. But if you bring in something like AI, and certainly AI is another trend that we are watching very, very closely, incorporating AI can really help drive success across all aspects of the patient journey. But perhaps we need to focus just as much on relieving some of the burden from providers, documentation, time and effort to get notes out and, and to communicate and correspond with patients, especially during pajama time, off hours time is really something that's a driver of physician and provider dissatisfaction right now. And I think we need to really look at seeing how we can use those tools to do it, but in a way that patients still remain comfortable with what you've substituted for real live touches with an actual provider, whether that be by phone or email, communication or notes through a portal.
- [07:50]
A
And Dr. Smith, let me ask you another question. I mean, just to follow up on this. What strikes me about me about you is whenever I get a chance to visit with you, you've got this tremendously positive and upbeat attitude. When you hear so much about physicians being burnt out, overwhelmed and so forth. And everybody is overwhelmed and we do have shortages. They are horrendous and getting worse. But how do you maintain that positivity? Because it's so engaging and such a great thing to have. Take a moment on that.
- [08:22]
B
Well, I appreciate that. You know, it's not easy, I will fully admit that. And there are certainly days that are really difficult to me. I circle back to my core. While I've increasingly taken on administrative responsibilities as part of my fte, I have always maintained a clinical practice. I'm an esophageal specialist by nature and training and experience and see a lot of patients who are on their second, third, fourth, fifth doctor to try and figure out what the right answer is because they haven't gotten to a satisfactory conclusion yet. And they're sort of circling around trying to figure out what can I do to get my life back. Imagine digestion in general is a pretty core piece of being a human being. But not being able to swallow or to not feel good when you're eating and therefore not want to eat or to drink is really a threat to quality of life. And so knowing that I can have that piece of what I do make a difference in those patients lives every day is a real satisfier for me and helps to balance some of the challenges of the headwinds that we face on the administrative and management and supervision side. But I also get the opportunity to train the next generation of physicians who are bright eyed and bushy tailed and really eager to learn so that they can move forward in their careers and start out on the trail that I began in gastroenterology a couple of decades ago. And I love the fact that as part of my responsibilities I get to go every Tuesday morning and work with them in the general gastroenterology clinic. And you never know what's going to walk through the door and who you're going to see and what kind of impact you can have on that patient's life in that moment. And you can do it while teaching. And that is a really wonderful thing because academic medicine, there's certainly a squeeze right now, right? And there isn't a lot of extra reimbursement that comes in for doing those teaching responsibilities, for helping to mentor and research and to be part of that academic mission. But it is so rewarding and if you get to do it and balance it with all these other responsibilities. I once had a mentor who said that the 24 hours of the week that he looked forward to the most were the Monday afternoon and Tuesday morning that he spent in his office practice and then doing endoscopy and teaching one of the fellows. And then he would wait from Tuesday afternoon until the next Monday lunchtime to be able to start to do it again. And that was the required part of his job. But his favorite part were those 24 hours. And I certainly see now from as my practice and my career has evolved why he said that to me. And I've kept that very close to the heart thinking about how do I manage my role and my career trajectory to be able to maintain those different pieces, because that probably is a saving grace right now. I think it would be really tough not to have that clinical grounding and try and do the work that I do where I'm trying to adjust physician behavior and get buy in on some very difficult things that we sometimes have to do in terms of shaking up schedules and work processes to be able to be more successful financially and keep the lights on.
- [11:40]
A
Thank you very, very much. And talk about Dr. Smith, as you get into 2026, what are you most focused on? What are you most excited about as you head into this next year?
- [11:51]
B
Yeah, I think there's a lot of stuff on the menu and I'll give you a couple of highlights. I think as I mentioned before, the financial challenges of today's healthcare climate. Gi, particularly in health systems, especially academic systems, is being asked to maximize its contribution to the bottom line. Endoscopy is a moneymaker when it' you know, and despite all of the headwinds that we talked about earlier with late cancellations and, you know, changing patient perceptions and insurance issues with authorizations, you know, I'm very proud that We've maintained over 10% growth year over year in our endoscopy cases that have been performed coming out of the pandemic. And you know, it's been great for us to see that keep going. We, we're really hitting, you know, aspirational and utilization targets in our hospitals, which makes it hard to squeeze more juice out of that orange. But what really strikes me is that if you look at some of the reports out there, like one that came from HST that showed that GI ambulatory center utilization, not all ASCs, but GI focused ambulatory centers, that the utilization rate is only about 59% on average nationally. So there's really a tremendous opportunity that seems to exist there if we can counteract some of those challenges that we talked about a little bit earlier. Scott. And you know, to me, that's a spot where I'm Collaborating with other folks in, you know, in our leadership teams and our ambulatory teams in our digital and technology or IT team to come up with ways that we can make some adjustments to take away some of that wasted opportunity, but to do so in a way that maintains physicians satisfaction. Right. You the easiest thing to do is to double book a whole bunch of slots and, and hope that enough people cancel or don't show that you still finish on time and people can go home to their families and get a chance to rest before they come back and do it again the next day. But really coming up with the way that we design schedules both in the office setting and the endoscopy setting, our inpatient coverage models, ways that we can do more, but to do it in a way that still maintains that work life balance for our providers. Because quite frankly there's a war for talent in gastroenterology and you know, a really good provider, even a brand new one fresh out of training, is going to be highly coveted and there will be salaries that are going up and up to try and entice them to go elsewhere. And so you've really got to design a job and a culture that makes them feel valued and appreciated. As difficult as it may be when you get the marching orders that say we've got to get our numbers up by X, Y or Z in order to meet our targets and figure out how to do that, go. And so being the person often in the middle between our frontline care providing team and the administrative leadership team is a challenge. But I think figuring out how to negotiate that successfully to make both sides happy is really something that in the next year to two years is going to be a continued focus for me. And again I would say, and I know this is ubiquitous in almost every healthcare conversation right now, but I would say again, how do we implement AI into everyday practice? From patient touches to the analytics piece, the process change piece, you know, where, where are we using IT most efficiently? Where are we deploying our IT resources to implement these changes? They can't do everything that's out there all the time. So figuring out what's our rank order for where can we use this emerging tool and all of its possible ways to improve patient care and improve bottom line in a way that works but also is sustainable. I'm a little bit confused and I think we all need to figure out better where patients will ultimately draw the line when they're not interacting with a human. I think about the phone trees now where it takes forever if you have A question with a reservation or a credit card, or you're trying to place an order, or you're trying to return something that you bought online and it takes forever to get to a human who can actually answer your question. If you add on top of that healthcare woes and not feeling well, and you're talking to an AI chatbot or even a synthesized voice, where are patients going to say enough is enough here? And I think right now the pendulum is swinging a little bit, but I think we have yet to figure out where it's going to settle out. So being part of that process to evaluate those tools, think about where they go in, but also maintain that high quality patient experience so that patients are giving you those good reviews that lead to more favorable patient demographics and demand for services in the years to come is going to be really, really critical for us and for everyone.
- [17:07]
A
And Dr. Smith, one last question. You've had this terrific leadership career. What advice would you give to emerging leaders? Any thoughts you'd give to emerging leaders?
- [17:17]
B
That's a great question, Scott. And I think these are probably true. No matter whether you're in healthcare or beyond. And folks who are coming up and are earlier in their career trajectory, I think it's particularly important that they think about how do they build their toolkit and how do they get help building their toolkit? Because you can think about it on your own and you can read books and you can watch lectures and you can go online. But really, to me, the mentorship network is very, very important. And I would say figuring out how to build that mentorship and support network quickly and broadly, not just in your discipline, but find folks who are successful in leadership across disciplines, across fields, across industries, I think is really, really helpful. And, you know, going along with that as your job evolves, as your career evolves, don't worry if your mentors come and go. Keep your Rolodex open. Don't, don't just discard someone because you haven't talked to them in a little while, because your needs will change over time and you'll probably rely on certain people more or less as your career takes twists and turns. But keep that stable of mentors around and that group will grow. It will morph with time, but it will be probably your greatest resource. I would say communication is really critical and figuring out that as an emerging leader, you will develop your own preferred communication style, but that will not necessarily match your supervisors, it will not necessarily match the C suites, it will not necessarily match your mentors. And so making sure that you check in and that your communication approach is tailored to each person that you are working with and that you don't make the assumption that that it's your style that is what they're looking for. I think is really important. And I would say that goes specifically for allies and partners who are working in your organization towards similar goals. Embracing collaboration as a leader, I think is really critical. Figuring out who your teammates are as well as you're the captain of a team. I look at my teams that I've led and thought, this is not people who work for me, these are people who work with me and I can't be successful without them. And I'm hoping that the work that I can do in advocating for them and the work that we're doing will make them even more successful. And in that vein, I would say it's okay to take credit for the success of the teams that you lead. And you need to do that to some degree because your leadership is an important part of why the team was successful. But I would argue it's even more important to thank your team and to make sure that they get a shout out as well. Particularly when you are managing up to your supervisors and your leadership at your institution, make sure that they know that you value the contributions that others are making and that you are working to keep your team value. We kind of estimate that if you lose a gastroenterologist in your practice and you have to backfill that slot, it's probably over a million dollars of lost revenue and probably more than that, just in the time it takes to fill the empty position, to get that person onboarded and then to get them credentialed with the different insurance companies so that they can have a full panel and a full set of clinical activity. And so, you know, to me, investing in ways to make those people feel valued, even things that don't cost you a penny, like giving them the shout out, giving them the credit, speaking to them and being an active listener when they raise a concern with you and making sure that they understand that you are there to advocate for them just as much as you are there to lead and that you respect and I think is important. And in that vein, I would say the last thing I would mention is don't be afraid to get dirty. Get down there with your team. Recognize that when you're short staffed, when you have extra work that needs to get done, when you're up against the deadline, yeah, it's okay to rely on your horses and make sure that they're getting things done but the more that you can do to be part of that solution and not just bark out orders but to actually be part of the implementation and to take on some more of that extra workload that's highly valued by the people that you are leading and I think that gets recognized by the people above you as well and that that will help you to advance in your career not just as a leader but but as an effective member of an organization. So I, I think those are just a few things. I'm sure we could come up with a whole bunch more but just a few that come to mind based on your question.
- [22:06]
A
Dr. Smith, just a fantastic pleasure to visit with you today on the Beckers Healthcare podcast. I love your leadership. I love getting to visit with you. It's always a pleasure. Thank you so much for taking the time with us today. We really appreciate it.
- [22:19]
B
Great to be here Scott and thanks so much for speaking with me.