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- [00:02]
A
Welcome to season three of Derms on Drugs, a video podcast brought to you by Scholars in Medicine, the best educational platform in dermatology and provided a no cost to medical providers. Derms on Drugs is we're cutting edge dermis, hit or miss comedy. I'm Dr. Matt Sierras from Docs Dermatology and each week I'm joined by residency buddies Dr. Laura Ferris from the University of North Carolina and Dr. Tim Patton from the University of Pittsburgh. And we use our 70 years of combined derm experience to discuss, debate and dissect the hottest topics in dermatology. It's everything you need to know to be on the Canadian derm and you actually have by listening. New episodes drop every Friday on Scholars of Medicine, Apple Podcast, Spotify and other major podcast platforms. And I highly recommend that you download the Scholars of Medicine app to access the full podcast video archive and explore the best derm educational content out there. Real pharma independent coverage of all of dermatology, supported by an amazing AI clinical consultant called Ask Simon. And today, I could not be more excited. We have one of my favorites. Actually, I will say it's the only person in the world who I think is a more entertaining lecturer than I am, which was a very big blow to my ego the first time that I was at one of her lectures. We've got Dr. Lisa Swanson, board certified pediatric dermatologist in the middle of nowhere, Iowa. I'm sure there's a name of the town, but Idaho.
- [01:21]
B
Idaho.
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A
Idaho. What am I saying?
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C
Yes.
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A
Middle of nowhere, Idaho. Yes. If it's in Idaho, it's the middle of nowhere. So I'm sure.
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B
But I'm sure we've got the potatoes. Iowa has the corn.
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A
Okay.
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B
I live in potato country. I live in corn country. Yeah.
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A
What? Do you know what it is that makes I Idaho? The potato capital, like, is. What is it about Idaho that the potatoes are so good?
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B
I think it's the temperatures and the soil. And you would not believe how cutthroat the potato farming industry is. You guys, I want to create a series on Netflix maybe, like Taylor Sheridan s about the cutthroat world of potato farming. Because they all want the contracts for, like, to be the potato supplier of McDonald's and chick fil A and in and out. And I even have a title picked out. Are you guys ready for it?
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A
Oh, spud.
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C
Nice. Okay, that's good.
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B
That.
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C
Is there any, like, potato sabotage that goes on?
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A
Yes.
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C
Really?
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B
Yes.
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C
Yes.
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B
I mean, it's literally like a soap opera in the potato farming yes.
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A
You would think of potato farmers as being very down to earth people.
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B
I know, but they want to sell their potatoes.
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A
Yeah, yeah. My grand, My grandfather always said money, money makes people act funny. Oh, yeah, that was one of his lines. That was one of his lines. So. All right, so for our listeners, we, we are having a very, we're gonna have a very interesting. Is probably gonna go in a different direction than what you're expecting. I'm about to say you're expecting some like, peds. Derm. Like oriented topic. No, no. You don't get what you expect when you come to terms on drugs. We have Dr. Lisa Swanson on to talk about burnout. And you might be, you might be thinking to yourself, burnout, we're dermatology people. Like, if there's anybody in the world who shouldn't get burned out, it is us. And if you believe that, what it means is that you don't really understand what burnout is about and that there's different types of burnout, different things that make you burn out. It's, it's not about working 70 hour weeks and no sleep and whatever we're going to get into really what it's about because I think it's something that a lot of people struggle with to some extent. And just knowing that you're not alone and that a lot of us struggle with it, I think makes a big difference. So before we get into our first article, Dr. Swanson, how did you kind of get interested in burnout? Because it was, you know, you and I had like a little interaction and I was something that came out that day and I was like, oh. And you're like, oh, when I, when I lecture about it. And I was like, what? Yeah, you're like, so how did you get interested in burnout?
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B
I got burned out. I got really burned out. And often when I'm doing my talks on burnout, I actually, I talk about like, how do you know if you're burned out? And there are like quizzes you can take, you know, like in, like, I remember all those teeny bopper magazines that, that I had when I was a teenager. Like, how can you tell that you're a good girlfriend? Like, you take this quiz. Quiz or whatever, like, tiger, you still get them. You still get them Sometimes. Sometimes. And so there are these quizzes that I say, or if your Amazon shopping cart looks like this. Because I actually took a screenshot of my Amazon shopping cart the day I ordered seven books about burnout, because I was like, how do I solve Any problem being a doctor, I read about it. I educate myself. I kind of learn how to tackle it. And so I ordered and read seven books on burnout and was able to utilize them to kind of build. Build the talk that I give about burnout. And so that's how I got into it. I got burned out.
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A
Okay, fair. And I'll get into it later for our listeners, but I also have. Have been a sufferer of burnout. So. But let's go ahead and get into our first article. There's been some really, really cool literature about this stuff lately. So, Dr. Farris, what do you got?
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C
Okay, what I have is actually something published really recently in JAMA Network Open, and it is moral distress and occupational burnout in US Physicians. So, you know, they, they basically, you know, start the paper with talking about, you know, physician burnout. Why does it matter? You know, it's important, obviously, because we want our physicians to be, you know, as eth. To be happy. But it also has, like, pretty real consequences because it is a big reason why physicians leave the workforce. And so, you know, we have a physician shortage, and there's projections of what our physician workforce will look like, but that kind of assumes people will stay in the workforce, and if they don't and a burnout is driving them out, that's really important. So what they did was they basically wanted to survey people about burnout, and then they ask questions about moral distress. And moral distress is basically putting in situations where you just feel like it's hard to know how to do the right thing or what the right thing is, or knowing what the right thing is, but not being able to actually do the right thing.
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A
So, yes, so there, there's a very specific. Because I, I get this wrong all the time. So I really looked it up before the thing, before we did this today. When you. When I think of moral distress, I always thought of moral dilemmas where, like, oh, your children, one of your children is going to die, and you, you only have enough food, you have enough medicine to save one. Which one are you going to save?
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C
Right.
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A
Like, that's a moral dilemma where there's no right answer. That's what I always thought moral distress was. No more distress is. There's an obvious right answer and the system is keeping you down. You know what the right answer is, but you can't do.
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C
It's not being empowered to do, not having the power to do the right thing. Sort of a way to think about that. All right.
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A
Yeah.
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C
So, yeah, so. And a lot of times what is our not having the power? It's basically bureaucratic brick walls. And what does that turn out to be in, you know, for us in medicine? A lot of times that's actually insurance.
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A
So.
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C
All right, so the, the national survey was over 5,700 docs. There were 135 dermatologists, which was 2.4% of the sample and broad spectrum. So about half of them were private practice, about a third academic, some BA and then other settings as well. So what did they find? Basically, 39% of physicians report high moral distress. The average was 3.29 on a 0 to 10 scale. And they then, you know, looked at the relationship between burnout, so it was relatively strong. So it was an R of 0.55 and depersonalization of 0.5. So what does that mean? Moral distress does explain some, but not all, all of burnout and roughly 30%. And it's, you know, moral distress they thought, they kind of said is responsible for like a third of the variability in emotional exhaustion and a quarter of depersonalization. So demographics important to look at. Women more likely than men to experience moral distress. And odds ratio 29.
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A
You know why? It's as, I mean, you might think it's just because women are weak. But that is not what it is.
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C
But I, I totally read that. I was like, why? Weakness. No.
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A
Yes.
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C
I think we're more, we're more, we're more caring.
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D
Right.
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A
You're better people.
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C
Better.
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A
You are better people.
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C
That's why anecdotally, patients who have women physicians have a lower mortality rate. Just putting that out there. All right.
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B
And patients will prefer a female doctor.
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C
What's that?
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B
Even male patients. Patients on the whole prefer a female doctor, I think because we listen.
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C
Yeah, yeah. No, so those are a lot of interesting gender differences.
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A
It's just swayed by the 60 plus year old men who think you're all nurses.
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C
Right.
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A
I'm going to, I'm going to get in so much trouble for this.
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D
You are.
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C
That's all right. You've already blown through two wives here. I think you're fine. Don't worry about it.
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D
Okay.
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C
All right. Older, who was less likely to report moral distress. Older physicians. So that might include at least some of us on this call. Married physicians also less likely to feel, to express, you know, moral distress than single physicians. I would imagine there's probably some correlation with age as well. So specialty mattered. So compared the people who seem to have the, the highest level of moral distress were actually emergency medicine physicians. And the group that maybe had some of the lowest were pathologists, which I guess makes sense because they're not actively dealing with, you know, patients, active patients at that time. And then there's like things about practice. So more hours, more distress.
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A
Although. Although that was a very weak correlation.
- [10:59]
C
Well, so it is. But when you're looking at those odds ratios, realize that they are doing it per additional hour of work week. So per hour it doesn't look like that much. But if you consider 50 versus a 40 hour work week, that's going to add up. So a lot of times when you have a continuous. I'm going to make the sciencey. Damn it. Even if it's supposed to be about distress and burnout, every time when you have a continuous variable, a lot of times you see the odds ratio and really what that's looking at is per unit. So it'll look small. But you know, when you're talking about a difference of like 10 years, then it starts to add up. That makes sense.
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A
Yes.
- [11:35]
C
And let's see. Physicians with high moral distress were far more likely to report burnout, intent to leave, and attempt to reduce clinical hours. So for dermatology, our specialist wasn't the high, our specialty wasn't the highest risk. And you know, but we do. So maybe our work hours aren't. And like you said, Matt, work hours was not the number one contributor to this. But we do have a lot of the same system pressures. And I think we also have a lot, I think, you know, this is me kind of editorializing, but we have a high volume of patients, which basically to me means like more interactions in which there's potential for moral distress. I think we also have a lot of issues of facing access barriers, prior authorizations. You know, I learned at some point that dermatologists prescribe more drugs than any other specialty. So, you know, we've got the time constraints, the time pressures, the prior auth, the number of interactions, and I think that those all become this fertile ground for moral distress. So, you know, punchline burnout. Maybe what we feel, you know, when you're like burnout is, you know, might be what you feel like when you're like, my tank is empty. But moral distress is like what happens when you're starting to feel like your tank is empty, but there's, you have to keep going. And you have, you're kind of asked to continue to not, not do what you think is best in your moral, in your professional judgment. So, you know, if we want to reduce burnout, it's not going to Be just like yoga and taking a week of vacation. We really have to think about, you know, ways that we can make sure that we are able to practice in ways that are aligned with, you know, what we feel is the right thing to be able to do with our patients. And I really think that that means, like, empowering physicians. Right.
- [13:41]
B
I 100 agree, Laura. Like, I heard somebody say, a doctor say once, if a canary dies in a coal mine, the answer is not to get a more resilient canary. And I think. I think we're all canaries in this coal mine, and slowly we're all dealing with these things, and we need to fix the coal mine in order to help all of us.
- [14:04]
C
Yeah, I think that's a great way to put it. So. Yeah. And I think that there's, you know, different ways that we can do that. I mean, one is like, advocacy. Right. So, you know, I can maybe have a better way to fly through prior arts, but, like, if. If what I am being asked to do is give suboptimal care, even though I can get to that answer quickly, there's still this level of moral distress. Right. So, you know, people will say, oh, what we need are more staff. And I do think we need more staff to help us so that we can get to the answer faster. But then I also think advocacy to make sure that within reason, we can get what our patients need and that we're not getting roadblock after roadblock from, you know, insurers or from systems. Right. I work for a big system sometimes, not always the insurer. It's also sometimes the system not agreeing with us, being able to do what we feel is right, too.
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A
So, Dr. Swanson, what is your first. If you had one thing you could tell your colleagues who are out there struggling, like, you know, just like feeling bad, overwhelmed, they don't. They don't look forward to going into work. What would you. What. What would you tell them?
- [15:24]
B
I think there's so many things but burnout. And also there's. I don't think there's a way to, like, magically fix burnout. Like, I don't think there's a magic wand. There is steps you can take to help make sure that you're living your best life in your practice. But even though my burnout was really bad before, and then I've made some strides to make it better, it's still there. And there are still some bad days and bad times. And so it is kind of a constant, just journey of adjustment. I think one of the important things is kind of think in your head, what would your ideal work environment look like? How many patients would you see in a day? How many locations would you go to? What would be the role of your ma? Would you have a scribe? Would you use AI to scribe? What would your late patient policy be? What would your no show policy be? What would be your perfect if you could eliminate all the things that annoy you, what would that look like? And then how different is that from your current practice setup and how changeable could that potentially be?
- [16:35]
A
And we're going to have lots of discussion at the end. Dr. Patton, what do you got?
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D
My deep dive was from a 2024 article in JAMA Network Open titled Physician Engagement and Addressing Health Related Social Needs and Burnout by Tabata Kelly et al. Health Related social needs or HRSNs are things that can adversely affect patients health that maybe aren't directly related to their disease. Things like food insecurity, housing instability, transportation barriers, et cetera. And the introduction that authors state that the Centers for Medicare and Medicaid Services updated the physician fee schedule to provide compensation for physicians. Addressing this HRS ends, I was like they do so yeah, That's a code G0136. I doubt it reimburses very much, but that is a thing. So anyway, this study was a secondary analysis of a previous survey that was performed in 2022. Table 1 breaks down physician characteristics, mostly men, about 70%, average age 51 years, mostly white. About a third of physicians surveyed reported high burnout, which meant feeling burned out weekly or more often. Table 2 examines engagement in HRSNs. Overall, it's a third, a third and a third reporting low, moderate and high engagement, respectively. Higher rates of engagement seen for younger physicians, women, black physicians, certain specialties like primary care, psychiatry and emergency medicine like 71% of emergency medicine engage in HRSNs, surgeons being very surgeon y and reported never being involved with HRSNs 42.6% of the time. So Table 3 gets to the nitty gritty as we would say. And is engagement in HRSNs related to physician burnout? The answer is yes. Moderate engagement associated with 33% higher odds of burnout and high engagement associated with 72% higher odds. That was kind of the overall numbers. When you tried to break it down like younger women, minority physician, it it broke down like it wasn't a lot at the time, statistically significant. But you know those overall numbers are there. So the point of the paper being like, look, if you can sort of take that burden away from physicians, maybe get social workers involved and things like that. Maybe you'd see less burnout. But it's a weird, like, you know, these HRSNs, like food insecurity and transportation. I mean, like, once every two or three years, I get a letter from the electric company saying, hey, does this person need their electricity because of the medical condition they have? And I'm like, yeah, sure, that would be helpful. But other than that, like, those numbers, like, I almost never get involved with HRSNs. So is that your experience as well? Like, do you see this as something we're dealing with all the time?
- [19:37]
C
I. I think the pd and I'm curious what Lisa thinks, but pediatric specialists very much do. When I see the discussions we have in my department, pediatric specialists do, and that's partly because, you know, I can. Kids can't advocate for themselves. And so if you see this kid is not getting better because they are not getting the right food or they are not getting the right care, or they do not have access. Nobody's putting their medicine on. I think you feel a little more obligated. Whereas we mostly take care of adults. But I do sometimes find it's like, here's a great plan, but I know that they don't have transportation, or, you know, there's like, there are things like, do I have to. Do I go in and, like, try to get them a car? No, I don't get that engaged. But it changes my plan, right? So I don't know. Lisa, what. What do you think? How often do you feel like you have to get, like, really involved in this for your pediatric patients?
- [20:38]
B
I think it is a really prevalent issue with my pediatric patients, how involved I get varies. We do have a pretty wonderful program with Idaho Medicaid where a lot of these patients will have a case manager. And. And it's the case manager's job in terms of handling all these logistics, making sure if they need interpreter services, they get interpreter services, managing transportation, managing kind of all of their different appointments. And so if I have a patient, usually if they are having some of these issues, they might be on Idaho Medicaid and they might have a case manager. And so I really appreciate that because I think these social issues do come up a lot in the pediatric space. And. And I think about them, and I ask about them. I have never used that code. Maybe I should. Maybe, you know, I'd have a few more nickels to rub together if I use that code. But it is something that we encounter a lot and at least think a lot about in the Pedstrom Clinic.
- [21:34]
C
Yeah. And I mean, I see it as like, you know, there are in. On sort of like a smaller level, you know, I have to think about for my patients, like, can you afford a $35 copay or do I have to give you something that's got a $10 copay or, you know, can you afford. Are you gonna, are, are you really gonna go out and buy moisturizers? Are you gonna, you know, get the over the counter product that I'm like, you know, this is very small scale relative to like, is your family gonna get fed tomorrow? But, you know, I do think it, it impacts the decisions we make.
- [22:10]
A
It, it matters a lot. And I doing contact term, you get a little bit more into this than other adult specialists because you're often telling people like, you got to get all new stuff. And getting all new stuff could be like, you know, 150 bucks. And then is that really going to fix the problem or did I just waste that 150 bucks? Or I need these. You need these special gloves for work. Is your employer going to pay for that? Can you just buy them? Your like it was. And so it's, it's one of my characteristics of useful pearls is it has to be cheap. If it's not like I, I would. I will never say in a lecture like, oh, here's a pearl. Use Skyrizi for granuloma annulare. Don't you. You can't do that. Like, it's not you. You've like. So, yeah, but I never, other than taking it into account in my making a plan or acknowledging for a patient because, you know, some of the ones who had real trouble with an easy one for us is transportation. Just acknowledging it and being like, oh, that's really hard. And I wish I could, you know, is there anything I can sign to help, like that kind of thing. But I think compared to primary care docs, like, we do not get real involved with this at all. Maybe Dr. Swanson does. I could see that.
- [23:37]
B
But yeah, well, and it sometimes affects treatment decisions. I can think of one in particular. Eczema, atopic dermatitis in the kids. A lot of these families will choose something like dupilumab because from their perspective, a once a month shot for their little is so much easier than managing all these different topicals that I might prescribe. And just kind of the time it takes for that. If they can think about it once a month and even if they can like come to the office once a month for it and Therefore they aren't having to have like personal time invested into it. Then a lot of times that's the decision they make, which is fine by me, but it does kind of guide the decision making process sometimes.
- [24:20]
A
Yeah. The branded drugs are often the cheapest thing for the patient. And that's like a crazy. The, you know, the $10 copay on a generic that actually cost $12 might like be worse for a patient than the $3,000 a month drug that they have co pay assistance on. Like, it's, it's hard to accept that, that, that this is the system, but, but it is.
- [24:45]
B
And also those copay cards can help pay down the deductible for the family. And so sometimes there's even benefit to the family unit in putting, you know, one of the kiddos on the biologic.
- [24:56]
C
Yeah, yeah. And I agree. This is like actually kind of one of those things that contributes to dissatisfaction, if not burnout for me is that like, I am like, help, you know, you, you'll meet with payers and they'll be like, oh, you guys, you're, you know, they are like, we want to put you in a value based reimbursement and you got to really help us to manage costs. And I'm like, okay, great. But like, why then why are you giving me a prior authorization for methotrexate or triamcinolone, right? Like, if I'm gonna, if I'm gonna do the work, I'm gonna get the Cadillac, right? I'm not gonna get like, oh, let me do that and hope that, you know, the triumph cinnalone works so I can then do another prior auth when it doesn't. And like, there's a lack of transparency. And you know, I like that stuff is very. Because you're like, I'm trying to be, you know, a good steward of dollars. And then you do something dumb like, you know, I do a lot of psoriasis. Acidretin should be pretty cheap. It's a, it's a perfectly fine option for a certain subset of patients, but it will be way more expensive than Skyrizi, for example. So I'm like, all right, Skyrizi it is, right?
- [26:04]
D
Yeah.
- [26:04]
C
And you're like, this is crazy.
- [26:08]
A
It's surprise. So it, if we had, if I had asked you guys before you heard Patton talk about this, before you ever saw this paper, if somebody had asked you, do you think that physicians who acknowledge and engage with health related social needs burn out more or less. Because basically what you're asking is do the Physicians who care more burn out more or less. What would your answer have been?
- [26:38]
C
More?
- [26:39]
B
And, and I, I love that you kind of phrased it that way, because sometimes when I'm talking to colleagues that are going through burnout, one of the things I tell them is that I think, I think some of the best doctors who care the most are the ones that get burned out because all that caring leads to so much of that moral injury and because you just feel like you're trying your best to be the best you can for your patients, and then these forces are upon you that seem to take priority over the work that you're doing, and that's, that beats you down and it takes away your joy. And so I think the more you care, the more likely you are to get burned out.
- [27:25]
A
Oh, I, I could not agree with that. I think it's the only reason Patton is still practicing.
- [27:31]
D
Well, I, I wondered about that with this paper. So this paper is like, okay, well, so the more that you're engaged with HRSNs health related, sir. Yeah, the, the more likely you get burned out. But I think it's, it's just a baseline personality thing. Like the, the physicians who have that personality where they're like, oh, my gosh, I, I have to figure out how this person needs to get to the infusion center, and I have to figure out how they're gonna. And like, they're the ones that are like, oh, I couldn't do that. I'm such a terrible doctor. And I'm, I kind of want to say, like, you need to be a little bit more realistic and practical about how you manage these patients. And it may not be, like, perfect, but it's, it's good enough and just take that as the win. So I don't, I don't know that it's. Know whatever we say, it's associative but not causative. I don't know that it's causative like you're engaged and that causes you to be burnout. I think that's just the personality of the person, and you just kind of overall need to take a, a step back and say you're not going to wind up with like, the perfect situation all the time. And that's, that's, that's okay.
- [28:46]
C
And I, I think, like, one of the things I've kind of told myself is, is, you know, it, like, I can try to get the perfect outcome for one person at hours and hours of costs, or I can try to give a reasonable option for one person, but then have, like, the. The bandwidth and time to help 10 other people in that amount of time. And at some point, like, there are things beyond my control. So I try to do what I can to help that is within my control. But it is, in a sense, not fair for me to do it at the expense of all of my other patients or to just say, then I don't take care. You know, I don't take, like, HS as an example. There are people are just like, I'm just not going to take care of HS patients. It's too hard. They've got all these psychosocial issues. They've got all these barriers to care. I'll just either, you know, spend all my time on a very few of them, or I just won't take care of them. And it's like, I'd rather have a happy medium where I've got an option. And I try to, you know, realize that there's limitations to. I cannot fix 25 years of, you know, history and problems, but at least I can try to do something and help make, you know, incremental pro. Progress for more people. I don't know if that makes sense.
- [30:04]
A
I think there. One of the things I always want somebody to do is like, detailed psych assessments of medical students, like, in the first week, and then 30 years later, who's burned out and miserable and who's hap. Because, like, here. So I mentioned it to the beginning, like, I have suffered from pretty extreme burnout at some points, and looking back on, it was very obvious that that was going to happen. So when I was a kid, my mom used to say, oh, Matt, you need to stop. You need to have the weight of the world on your shoulders. And. And I would see, it was like, when I. We were kids, they had, like, the Ethiopia. The people in the. You know, the kids starving and the. Whatever. And I used to cry because I was convinced that as an adult, the only way that I could be a good person was if I was a missionary in the poorest, most dangerous, worst place in the world I could possibly find. Because other than doing that, like, you're not living up to what God wants you to do. Like, that's. That's. If you love other people the way you love yourself, you should be like, there's nothing you can do other than you got to get to the worst. But then once you get there, you don't have the resources to help them, so you still can't. And I would cry and cry and cry about this. I should not have been like, somebody should have been like, don't be a doctor. You're like, you're, you're, you're. You're putting yourself in the. Like just every day it's gonna. Every single patient. When Patton's, like, when Patton said, like, some people try and help him get to the infusion center, I was like, oh, my God, if I had that patient, I'd be, so how. How are you gonna get there? What am I gonna do? Can I. Well, I wouldn't help him. I would just feel bad about it. Like that. That's the, the problem that I had.
- [31:52]
C
I almost feel like, what would you
- [31:53]
B
have done instead, Matt, if you weren't a doctor?
- [31:56]
A
Engineer. But I would have been a terrible engineer. I would have been one of the salesman engineers because nobody would trust me with like, getting. I. Yes, I could come up with, like, the general idea of like, here's, here's what would work now. Somebody else figure out all the details and I'll. I'll sell it to people that would, That I. That would have been good for me.
- [32:19]
C
You know, one of the papers that I had looked at and I didn't do was sort of interesting. It was out of Duke. And they looked at. Even though it's out of Duke, I can still say it's a good paper. Now, I, I love the Dirk. I love the Duke Durham group. But, you know, I think they've done a really great job of trying to think about how to support their faculty. So they sort of did a. A study on what if we basically just hired more nursing support. And then, you know, you think, okay, good, I'll spend less time on the in basket. But really what they had them do was to just triage more things so that it didn't. It. They just went into like a spot check or a video visit and, and they didn't. I think it's just when you see the overwhelming, like, I. Now I'm worried about this spot. Now I can't get this. Now I can't. It's like, instead of bombarding you with a bunch of stuff that maybe you can help with or maybe you can't, somebody else just triages it so you can show up in the moment and deal with it. Which I thought, like, my first thought was like, oh, good, it decreased in basket time. But I think it almost just like, decreased the cognitive burden of just seeing, you know, I have this problem. I have this problem. And I do think, like, that is one of the things we need to do for people Even if we can't fix it, you cannot expect physicians to just hear every complaint, take every challenge.
- [33:39]
B
And there are so many ways that we can receive those messages now. We have patient portals, we have emails, we have, you know, all of these. We have reviews online giving us feedback. A lot of institutions love surveys that they give to the patients. There's so many ways that we're hearing all of this. That, that, that gets hard too. That gets really hard. I sometimes open up my inbox and I'm like, please have nice messages today. Please have nice messages.
- [34:08]
C
Yes.
- [34:09]
D
Yeah, actually stop reading my reviews. We get those like, I'm, I'm 53 years old. This is the doctor I am. I think most people like me. And the people that don't like me, it's a personality conflict. It's not, they're a bad patient, I'm a bad doctor. We just don't click. And I'm not going to freak myself out about the patient who didn't like me for this, that or the other, because most people do. So I think they're helpful. I tell residents, like, read these at the beginning. Are you careful career? Because you will pick up like a couple of good things. But at this point, yeah, you know, so that's another way. Avoid burnout.
- [34:48]
C
Yeah. The other thing, because I do think like there's a little bit like older people are less burned out. Right. And so I do think, and I
- [34:55]
B
tell like new, that's self selected.
- [34:57]
C
What's that?
- [34:58]
A
The reason that, the reason that they're still an old doctor is that they didn't get burned out. Well, that's like survive, survival.
- [35:06]
C
Here's my, my theory. It's that because I'm somebody who went from like being 20 years in one place in practice and what did I see? I saw lots of return patients. They were people who had chosen to come back to me or their friends who'd been referred to me. So they all came back because they liked me. Then I showed up at a new place where I just kind of got. Whoever like called the phone room and they hadn't really picked me and they had never chosen to come to me. And suddenly I felt like people don't like me as much. And I thought because it's the south. And then I realized, like, it's, it's, you know, I'm like, they just don't like me because I'm a northerner. And now I've realized, like it, it truly is that when you, the longer you're in practice, people come back to you because they choose you, which is, means the earlier you are in practice, you're just kind of getting an unselected group of people and you're not going to have like a connection with as many of them and like, just wait it out because it does get better. And you do sort of develop a patient, a type of patient who, you know, clicks with you and they come back and like, for the people who are young and are like, this sucks. I'm tired of listening to patients complain. Like, don't go in and try to make every single patient happy. Do the right thing by patients, but give it some time because you are going to sort of build up your patient population and you are going to like them better.
- [36:30]
A
Okay, that's, that's pretty good, Ferris. All right, I, all right, I've got some, some little vignettes I put together.
- [36:35]
C
All right.
- [36:35]
A
That I want to, I want to hear how you guys would think about each of these if, if, when they happen to you. And they're, they're supposed to be ones that are very relevant to us as, as dermatologists. All right, so you're 30 minutes behind. You can see that the waiting room's full. You walk into the room, you see this guy like from before you even started the exam. You can see that he's got at least five squames and his field cancerization all over his primary care doc told him, like, oh, you need to get these taken care of your blah, blah. And you know, this is get like, you probably need like 40 minutes with this guy. But every. If that means that everybody else the rest of the day is not going to get like, you're going to walk in the room to somebody who's already pissed. And so instead of like, oh, how can I help you? What's going on with your bids and having a good exchange or you can help them now. What's it. You know, I, at my job we would never do this and we would blah, blah. And you're trying to explain why. So do you in the right. I'm not going to let you have the easy answer. Oh, I'm just going to handle one today and then have them come back. No, your next appointment, your next available appointment is in four months. And you think he'll be dead from a squam by then. So what do you do?
- [37:47]
C
Because this does, this happens. So one I do say, wow, you've got a lot of skin cancer and pre cancer and we didn't get here overnight. And we're definitely not Going to fix this in one visit. So there's a few things we need to do. One, you got three things that to me are the most concerning. We're going to biopsy those three. Two, you've got these areas that are so sun damage. I can't tell what's pre cancer and cancer. So I'm going to give you a cream that you're going to treat it with. Three, I noticed I'm looked at, you know, maybe we talk about a prevention thing and then I say we got to do all these things and, and then when one of those is me skin cancer, when you come back from your visit, I'm going to buy up see another one. But I just say you and I are going to get to know each other really well because you're going to be seeing me a lot. So I'm just starting this, this process today. And then this is going to be a continued story and relationship.
- [38:41]
A
All right, so Ferris short changes them.
- [38:43]
C
I don't. Not short changing. You know what I think the worst
- [38:47]
A
they got to come back for is
- [38:48]
C
biopsy 25 squams in one visit. And then one of them will get like, you'll never keep track of them. I think it is biopsying three and then starting a treatment plan and going through is a better way to practice than to biopsy 10.
- [39:03]
B
I would give Dr. Ferris an A. Thank you for that answer. I thought. Yes, I thought you managed that beautifully.
- [39:09]
A
Dr. Patton, what are your thoughts?
- [39:12]
D
Yeah, right. This is not. We're gonna make you better in three. It's not like the horrible psoriasis patient that you can get Skyrizi for. And they're going to be better in three months. This is a two year patient and you tell the patient that you're a two year project. I would also say systemic wise things that help. I mean I work with residents. That helps because I'll tell the residents, like, look, I'll, I'll handle the biopsies here. I'll talk to this particular patient about what we need to do for the next two years. You guys clean up the people that have been waiting 30 minutes. I mean that, that is like. Okay, well that's not going to work for me because I'm in private practice. Fine, you're right, it won't. And maybe that means having really good assistance in your office. That can help with a lot of that stuff. And then finally just another system wide thing is I have ADD on visits. I mean if I look at my schedule, two weeks out, I have 30 patients on the schedule that day. I'll see 38. Because I have these slots where my manager knows if he sees somebody and he needs to get them back in a month or six weeks or two months, we have those slots. And if they don't get filled, they get filled. Right. I mean, the waiting list of people that want to see dermatologists. My office manager be like, get somebody in that spot. We didn't fill it. It's. We need somebody there two days from now or tomorrow. I mean, those are system wide things. And maybe not everybody can do that, but that helps out a lot for that.
- [40:43]
C
I mean, people can't like make your office, like make sure that you have a system where you never have no appointments for four months. Right. You, you've got, you know, slots, you hold. It is much easier to bring somebody back than it is to feel like I got to do it. All right now I think that's a very important point. And we can all.
- [41:03]
A
Let me, let me, let me tailor the scenario now to Dr. Swanson. So Dr. Swanson, you walk in the, you're, you know, 25 minutes behind everyone. You walk in the room. There's a kid, he's four, he's got horrendous eczema. You know, four different, you know, he's got moms there, she's got five other kids with her because she doesn't have anybody to, whatever. They live four hours away. They said they've been, they kid like, oh, it was so hard to get here. And the blood we need. And like, what do you. How you know? And you're like, I need, I need time with this person. I'm already 25 minutes behind. What do you. And they, they're four hours away. You live in Idaho. That's not uncommon for you.
- [41:46]
B
No. Yeah.
- [41:48]
A
What do you do?
- [41:49]
B
I walk right in, like one fell swoop. Give the dupixent shot. Just like one felt. Just kidding.
- [41:55]
A
Yeah. Leap through the door.
- [42:02]
B
No. And I hate running behind. I. It's like my, I sometimes envy clinicians that running late doesn't bother them because I feel so much anxiety when I'm running late. It just ruins my day. And I hate the look that you get when you walk in to the patient room and you're late. You can tell on their face just how they're upset with you. And I hate that. I want to avoid that like the plague. So I would, I would walk in, I would sit down. I would be not rushed, but efficient in the questions that I ask in the way I have my MA help me. You know, maybe they can print out the referral. And so then I have the list of previous tried and failed. And I don't necessarily have to spend the time going through all of that. I typically like to give families choices for their treatment plan, but maybe instead of five choices, I write down three. So I'm still giving them some things to choose from, but I'm also being efficient and recognizing that they live four hours away, maybe a rural environment. What's going to be the setup where they can get the best treatment plan? Do they have access to a compounding pharmacy so I can use some little tricks in that way?
- [43:21]
C
Or.
- [43:21]
B
Or would something like Dupixent not work because they worry about giving the shots on their own and they live too far away from an office where it can be administered. So I would try to swiftly get through all of that and get them to the point where I can make them better, which is my favorite part. And I have a lot of toys in my office, and so I have coloring supplies and toys so all six kids can be happy and entertained.
- [43:49]
A
Okay, all right, all right, let's go. Let's go to scenario number two.
- [43:55]
C
Right.
- [43:56]
A
Insurance companies keep cutting reimbursement and increasing burden on prior auths and everything else. So, you know, it's getting to the point that by the end of every day, you know, you finish the impatience at 5. You've got an hour, hour and a half. Like, you've, like, you need to do the prior auths. You need to get through your inbox and call people back. You need to do everything else but your kids. Like your kids. Sports games are at 5:30 and do you stay and like you. So you have the choice between I can feel like a good doctor or I can feel like a good parent. And this is several times a week event. And Right. You could slow down how many patients you're seeing, but then people would have to wait, you know, six months for an appointment to get in to see you. You could hire more staff, but, you know, maybe you're part of a group practice and they are like, look, you've got the same staff as everybody else. How do you. Let's. Let's start with Dr. Faris, who I would imagine has dealt with this way more than Dr. Patton or I have. Although we both have kids, we're probably not nearly as good a parent as Dr. Farris is. So. So Dr. Faris, I'm sure. So first, is that a scenario that is familiar to you? And how do you I know it's familiar to a lot of our readers. How do you deal with it?
- [45:19]
C
Yes, so that is definitely. Now that I'm an empty nester, it's easier. But yes, it like there was, there's always been like more to do than I have had time in the day to do. So a lot of it is, you know, prioritizing. So what will I do? I will leave. I mean my kids, we have a frank con. We have friend conversations. Like I can be there for some things, I cannot be there for everything. Like, I'm probably not going to be the mom who's going to come and photocopy for the teacher six hours a week at 10am that's probably not going to be me. And like I'm probably going to send in store bought granola bars and not like homemade granola when there is a thing. All right. And I'm going to opt for like bringing the water bottles, not, you know, making the game. So A, prioritizing what you're going to do. And then B, like I would, I would generally, you know, and I might be there for three quarters of your game, but not the whole one. But I want, you know, it's still important to me and you still matter to me. And then, you know, I would go home and do a lot of work at night after I put them to bed. So I would say with having kids, kids, like one of the things I learned is get them on a schedule, have a predictable bedtime. So I knew 8:15 on was time I could do stuff. So it made it easier to leave, go to the thing, be there, present for that activity, and then know that I had time to work later. That's what I did.
- [46:43]
A
And, and the thing that is so first, that is very impressive. You have much more discipline, shockingly, I know, than I would ever have because none of that would ever happen at 8:15. But the, the thing that drives me insane about that is that our response isn't like, because every other job in the world they'd be like, it's your job. You just, you know, you go home at the end of the day. How much the insurance companies take advantage of the fact that like we care and we don't. Like, we are the ones sitting there face to face with the patient who's like, my insurance company, it's gonna be. And you're the one who has to do. And they, they so take advantage of that, of that. We are good people who care about patients. And it, I, I don't. It's Like, I don't have an answer. Just is so frustrating because it's like the only answer is the patients. And like you, I don't.
- [47:45]
C
I think you can also say we have tried. I've appealed. This is not where we're getting. This is what we're going to try. If it doesn't work, we'll be able to try again. But there is also the, like, everything has to have a. You, you do your best, and then you work with the resource that you have and then you go back. Right. And I, I fight for the things that are worth fighting for. And I maybe, you know, I fight hardest for the things that are most important to be fought for.
- [48:13]
A
Well, I'm, I'm largely, though, talking about the idea that inflation adjusted reimbursement has gone down substantially. Right. Over the decades. So we're getting more and more administrative stuff, and we can afford less and less staff to help with it. And that's because they know they can take advantage of us. And it's just. It's maddening. Patton, what do you think about this?
- [48:38]
D
About what? Now, there were two things that are kids.
- [48:41]
A
The two things that the kids. You have to stay at home. Mom, you had, like, an actual parent at home to do everything.
- [48:49]
D
So that's the answer.
- [48:52]
A
Fair. At what point do you think there will be a breaking point where the medical system has taken so many resources away from providers? Like, what's going to happen?
- [49:08]
D
I. I don't know. I don't think on that level. I go in, I see patients, I go home. How the system works, let it work. I'll figure it out. I just don't get involved. I'm not. I'm a guy that, like, I deal with whatever's going on. I'm not like a, hey, here's how we could make this better. Which is why, like, I do what I do, which is like, nothing. I see patients.
- [49:33]
C
You live in the moment.
- [49:36]
A
Yes, he's present. All right, Dr. Swanson, what are your thoughts? And then we're going to move on to. I hope Dr. Patton has some. He's in Italy, so I don't know if he has. We'll see if he's got some trivia for us. Director Swanson, what do you think about that? That idea of the system taking advantage of not just, not just physicians, but physicians, PAs, NPs, nurses, like, everybody who's face to face with the patient, the hospital administrators, the insurance company people, they just keep squashing us because they, you know.
- [50:12]
B
Well, and it's so interesting Because I think it's so much easier for patient dissatisfaction to be routed towards us than it is to be routed towards the insurance company, even though it's the insurance company making all of these calls. Because. Because it's, it's hard enough for me to call the insurance company and worm my way through the call line to actually get to talk to somebody, and then even that person can't really enact any change. And so imagine being a patient, trying to advocate for yourself. That's just not going to work. And then have you ever tried to put a Google review for an insurance company? You can't do it. You can't do it. They don't allow it. And so how are they allowed to, like, be invincible to all of this? And then all of it comes to us. And I wish I had more of Dr. Patton's attitude where I just go in, I do my best job, I go home. That, that sounds really a lot better. I. My stubbornness gets a hold of me and I feel like every opportunity to fight is, is my opportunity that I should take. And to quote Handmaid's Tale, don't let the bastards bastards grind you down. Like, I just feel like it's my role to fight, fight, fight and push back. Because the only reason they say no and make all of this so hard is because so many people won't fight. And they know that there's a certain percentage of times where if they say no, maybe 50% of the people give up and that saves them money. And so my stubbornness takes hold and I'm like, no, I'm going to make sure that they pay for this.
- [51:50]
A
So what? Just the last thing I got to add is, I don't know if everybody knows this, that insurance companies are immune from getting sued. So if you're so say pat and has somebody walk in with pemphigus and literally their insurance policy says, we will pay for rituximab for pemphigus. They paid for that policy. And the insurance company says, nope, denied. And Patton submits the appeal. Nope, denied, we don't pay for that. And Patton submits another, nope, denied, we don't pay for that. And Patton does a peer to peer. Oh, oh, you know what it is? It's right there in the policy. We're supposed to pay for that.
- [52:22]
C
Huh?
- [52:23]
A
Don't know how we made that mistake. And the patient died from their pemphigus in the meantime. Totally immune. That is what the government's. It's called ERISA E R I S a health Insurance companies. The only thing. If you intentionally. If you found something that said, hey, let's try and save some money, we know this is covered, but we're trying. If they. If they're just like, oh, we just screwed up our, you know, our. You. They are literally immune, like, federal to federal law. Cannot sue them no matter how much they. If they kill people. Can't. Can't do.
- [52:57]
B
My gosh, it's crazy what they are able to get away with.
- [53:01]
A
Yes. Yes.
- [53:02]
C
Yeah.
- [53:03]
D
All right, Doctor, coverage of rituximab is actually very, very good.
- [53:07]
B
I can.
- [53:07]
D
Could get it for anything. Anything peptid related.
- [53:10]
A
Okay. All right.
- [53:12]
D
Maybe that's why I don't have the burnout.
- [53:14]
C
It's called all, and then they don't know the difference and they just approve it for everything. That's the trick.
- [53:21]
D
Yeah.
- [53:22]
A
All right, Pat. And you got any trivia for us this week?
- [53:25]
D
I do. So it's. It's burnout, burns and quotes. It's all about burning. Burning things. Okay.
- [53:32]
A
Okay. Dr. Swanson, the rule is you just have. You have to wait for Dr. Patton to finish saying the question. As soon as he's done, you just. First person to shout out the right answer. But you only get one guess. Like, if you get it wrong, you're out. You can't, like, shout out a bunch of things.
- [53:47]
D
All right, number one paper actually ignites at around 480 degrees Fahrenheit, not this temperature as suggested by the title of a Ray Bradbury novel.
- [54:00]
C
451
- [54:03]
D
Fahrenheit. 451. Lisa, you're muted. Yeah. So unmute yourself so you can answer.
- [54:09]
B
I didn't know the answer. It wasn't. So I. I'd love to be able to blame it on the mute, but I didn't know. Way to go, Laura.
- [54:15]
D
I saw Lisa Mouth Fahrenheit 451, so I'm giving it to her.
- [54:21]
C
Discriminated against. All right.
- [54:23]
A
You're gonna burn.
- [54:24]
C
Yeah, don't burn me out on trivia.
- [54:27]
D
All right, all right, all right. Point goes to Ferris. All right. In the chorus of the 1970s disco hit disco Inferno by the Tramps, what repeated refrain immediately precedes and follows the phrase disco inferno?
- [54:43]
C
Burn, baby, burn.
- [54:45]
D
Yes.
- [54:49]
A
I think Ferris might have a little bit of a pyro.
- [54:53]
C
No, no, it's all coincidence that I know this.
- [54:56]
B
This.
- [54:57]
D
We all know the song, right? Burn, baby, burn Disco inferno Burn, baby, burn Burn the mother down. I'm not going to sing because I can't.
- [55:06]
C
Okay, okay.
- [55:07]
D
All right. Number three. I'm in Italy, so I had to come up with an Italy themed question. So Nero reportedly fiddled while Rome burned, which is impossible. The fiddles weren't invented until the 16th century. According to most historians, his death marked the end of what Roman dynasty?
- [55:28]
A
Justinian.
- [55:29]
D
No, th. This was. I thought the first two were guineas, but. And this was going to be what decided it. But clearly already. This is a walkway. This is a walkway win for Ferris. So those first five emperors are considered to be the Julio Clark Lotian dynasty. And when Nero died, that ended it. There you go.
- [55:54]
B
Oh, wow.
- [55:56]
C
All right.
- [55:57]
B
I have. I feel. I feel morally injured by Dr. Pat today.
- [56:03]
D
Lisa's burnt. Lisa's burned out from this podcast.
- [56:06]
C
She's leaving more burned out than she came in.
- [56:08]
D
We've.
- [56:12]
A
All right, well, Dr. Swanson, it was fabulous having you on the show. You know, this topic was as much fun as it could possibly be. So thank you for coming on and joining us. To all of our listeners, hope you laughed once or twice, Hope you learned a few things, but mostly, I hope you're planning to join us again next week. And until then, I'm Matt Zyrus.
- [56:32]
D
I'm Tim Patton.
- [56:33]
C
And I'm Laura Ferris. And we are Derms on drug.