What does the future of healthcare look like? Even before COVID-19 placed an unprecedented burden on the industry, medical care has been on a state of transition into something more attuned to the needs of contemporary society. Where does the industry stand now? What challenges do professionals and providers face? What opportunities are in the horizon? Ben Baker devotes this episode to explore this topic with Dr. Michael Lalor, the Chief Medical Officer of Trellis Supportive Care, a North Carolina-based company specializing in hospice and palliative care.
This show is all about how do we move the needle? How do we help people be better? How do we create opportunities to allow people to find the best part of themselves, understand who they serve, why they serve them, be better doing it, and understanding what they're good at, what they're not good at, where their real value is and who they're valuable to? We're going to go in a completely different direction. I have Dr. Michael Lalor on. We are going to talk about the future of medicine.
This is not something I've talked about before, but in the world, it's something that every person and every business owner needs to be taking a look at to sit there and say, “Where are we? Where are we going? What are the challenges? What are the opportunities? What should we be thinking about not only for our health but for our parents, our children, our employees, and how can we inform ourselves and educate ourselves so we can be able to make the best decisions to be able to help people moving forward?” There's a lot of things moving forward that we need to be aware of. Dr. Michael Lalor, welcome to the show. Let's get into this.
Thank you for having me. I appreciate the opportunity.
Before we start, let's get people to have a little bit of understanding of who you are, what you do, and why you do it because you, from what I understand, are more at the end of life stage of the medical profession. Let's talk about where you came from, your general thoughts and ideas, then we can get into healthcare in general.
I'm the Chief Medical Officer of the large healthcare organization called Trellis Supportive Care in North Carolina. We provide hospice and palliative care services to patients in the central part of North Carolina, the thirteen surrounding counties. It's an interesting niche medical field that I've found myself in and appreciate the opportunity of taking care of patients that have that critical need and being able to do it in a compassionate manner and fulfill something that the rest of the healthcare system doesn't always do well.
For someone who's availed themselves of the palliative community and had to go through that, the compassion that being in that business and understanding day after day, you're dealing with people at their absolute weakest at the time where they are suffering and you're trying to make their end of life better. The people that are involved, the nurses, doctors, therapists, and whoever is involved in the care of these individuals to be able to make the quality of their life as good as it can be at the end of their life is an amazing thing. I'm not sure anybody who hasn't gone through this truly understands how magical some of the people that work in this industry are.
I can tell a little bit of how I landed here because it was an unexpected trajectory, but 100% correct. The heart of what we do is focused on the quality of somebody's life irrespective of the quantity of life that they have remaining. One of the most common things that I hear is a variant of if I only knew sooner that how much it is about taking care of somebody and helping them thrive regardless of what the time that they have remaining is. It's often mistakenly thought of almost the opposite that it's about less of something and then being forgotten by the system. It's not the case at all.
That's an important thing because when people are faced with those end of life and there is the stage right there where they may or may not be cognizant of their mortality but their family is. I want to find out, first of all, what drove you to get into that arena? Second of all, how do people handle that? From the decisions that need to be made that do not resuscitate all the things that go along with those end of life decisions and being able to make not only the person as comfortable as possible, but to help the families through those end of life decisions, to make sure that they don't feel the regret, angst, and worry that come along with that whole period of people's lives.
I can start with how I landed here because it wasn't something that I predicted. When I went to med school and residency, I got out and trained in hardcore academic medicine. It was my goal to be the smartest person in the room and make sure you know about it. I was on the teaching faculty, helping med students and residents. I loved that component of it. I was in a smaller practice that received a phone call one day from a local hospice agency that was looking for a medical director. I was voluntold that I was going to be the new medical director. They were looking for someone else in the practice, more senior and I’m the new guy who can go make us some extra money so I went over there.
It was a small portion of my time. I saw patients in a hospice facility at the end of their life. I didn't know what it was at first, and radically different than what I trained in. I quickly found that I had a joy in it because it was providing care in a manner I was unfamiliar with. The story that crystallizes in my mind when I was like, “This is for me,” was there was a patient who would stop in and say, “Is there anything I can get?” She jokingly said to me, “Yeah, good stiff drink type of thing,” and we laugh for one second. I went home and went on my merry way. At one point in time, I wonder.
The next time I went, I brought a bottle of gin, a martini shaker, two glasses, and knocked on her door. I was like, “About that drink.” We sat there and made two more martinis. I sat down with the lady and had a drink. It's sore as a person and we talked about what was important to her, what she hoped for, and what it meant in her stage of illness. It was truly magical. It opened my eyes to a different type of care that I was taking care of a person and not a disease. It grew from there. I kept on going on and on, and becoming more involved in patients at end of life, as opposed to primary academic medicine. I went on and made a full-time career of it. I have appreciated the opportunity to make a difference in patient's lives at the end of their life. It's been a fantastic opportunity for me.
I want to talk about that passionate versus dispassionate doctor because you hear time and time again about the dispassionate physician. The physician that keeps an arm's length. They do their job, but there isn't that same human connection, whether they're too busy or it’s something they’ve been trained to do or whatever it is. I want to talk about that because, in the end, we're dealing with human beings at their most vulnerable when they're scared. I don't care if somebody is coming into the ER, getting their appendix out or having a heart transplant, or end the life. We're dealing with people when they and their families are scared. They're vulnerable and sick. I want to talk to you about that humanity that seeing the people as people versus seeing them as a disease, is that becoming more of a reality or you see that from individual physicians, or is that something that is becoming more of how doctors are being trained?
It's a little bit of both. I don't think anyone is formally trained that way, but there's this confluence of external factors that result in it more often than not. I'd like to believe that the majority of people that go to med school do it for all the right reasons. They want to help people. They're truly interested in that intersection of care and science. They recognize the benefit that they can provide to others. At a system level, it's almost beaten out of them. Some people have a predilection to the natural disproportionate power in a physician and patient relationship.
You're the expert by nature, that's why they're coming to you and can lean to that dispassionate side that you're saying. Also, changing employment, methodologies of physicians, increased productivity, pressure, external forces driven by electronic health records and data entry makes it hard at a system level to guarantee the care that individual in front of you. When you first started out, you were looking to provide and you become a cog in the machine. You're looking to go and it's almost a natural occurrence of that is the automaton physician.
The prototypical interrupt the patient within seven seconds of them talking. They’re like, “Doc, I'm here because.” You are like, “Okay, thanks. I think you have this. Take your prescription, go on the merry way.” He didn't even finish the first sentence the majority of the time. I don't know that people are formally trained that way, but the system results in a large number of individuals ending up that way.
I have this vivid memory back in 1991. I got into a hockey accident and I get L4 and L5 fused. I went up to the nurses within the doctor's office. I said, “He's a bit of a prima donna. Is he that good?” The nurses said, “He doesn't have a God complex. God has his complex. He is that good. He doesn't have a personality. He's overly demanding. He wants things an absolute specific way, but he's the best in the hands you want working on your spine when the pressure is on.” As a patient, cook solace in that and it alleviated a lot of the fear that I had, but it came from the nurses and it came from the nursing staff anesthetist. It didn't come from the actual doctor itself.
On the other hand, I've also had doctors that have sat down with me for 30 minutes and explained to me exactly what is happening in a particular situation, in a high-risk, highly volatile situation, because they felt that I needed to know. There's a lot of pressure on the medical profession. I want to get into this, that it's how the medical profession has changed because of the digitization, legality, having to cover yourself, and all the paperwork that goes with it. I want to talk about how from when you first started to where you are now and what you're seeing moving forward. How have you seen the medical profession change? How has that changed the people within the profession itself?
There's so much there and it's such a turbulent time for the profession. All of the healthcare. I've almost moved away from referring to the doctors because the reality is these same pressures exist for nurses, case managers, the entirety of the system. I now use the more umbrella term, even providers. Stocks linked to thinking that we're special, but need to recognize we're part of the system. The other parts of the system are having the same difficulties that we are and told them, “I don't think the whole thing gets better.” It's interesting what you said to start the technical, but perhaps poor bedside manner. The great person with unknown technical expertise. There are a value and risk in both. It's unique in healthcare.
Much of it is about how you feel. If you didn't have the chance to speak to the staff with your spine doctor to hear that he is that good of a technical expert, that it's worth almost ignoring some of the personality, things that come with it, you may have not have had the opportunity of benefiting from his technical expertise. You may have been like, “This guy is a putz. I'm stepping away.” The flip side of it, how valuable it can be to have a better understanding of what's going on. That takes time and a good bedside manner. Finding both in the same individuals sometimes can be hard. The flip side of it, unfortunately, becomes the great salesman who may not be the best actual technical provider or out there to be aware of.Take care of the person, not the disease. Click To Tweet
That goes beyond the medical profession and in everything.
It's not a medical thing at all. These system-level pressures that are changing the actual responsibilities of all healthcare providers are the biggest differences that I have seen. It's a time-based scenario. When I got out of training, it was at the peak of the HMOs. The older providers that I practice with would rally against the evil of the HMOs and how they're changing everything in their day-to-day practice. It wasn't the good old days type of thing. Being newer into the system, it's all I knew. I was like, “What are you guys talking about?” Now that I'm a little bit on the backside, it’s like, “DHR is killing us all. You have no idea what it was like. The glory of paper.”
People are training with nothing, but DHRs are like, “You used to write on paper and you think that was good? That's crazy to that.” It's interesting that the windows of time are looked at individually. Going back to the majority of providers who want to spend care at the bedside and do not want to be pulled away from the actual provision of care of an individual that's seeking their help, guidance, need, and specialization. These external systems that revolve around billing, documentation, coding, compliance, legal CYA that are now driving the dominant portion of their day is leading to an overall amount of distress as a provider, burnout, fatigue, dispassion, lack of joy in their day-to-day world.
Sometimes, it, unfortunately, translates into the care that's being provided, inappropriately gets taken out on the patient. Even if it's not a passive-aggressive taken out, that may be strong words as the individual receiving care, you feel it, like the physician who spends the majority of times talking to you with their head in a computer screen trying to transcribe the things that you're saying as opposed to looking in your eyes. How different do you feel about the care when that goes on? Even though the care may be the same, it's having a universal effect.
That technology portion of becoming a doctor or a nurse or a radiologist or whoever member of the healthcare system, you're now having to focus on the technology as much as you are on the patient. It's a serious thing. I used to do keynote addresses in front of large crowds, 500, 1,000, 2,000, 3,000 people. You got a clicker in your hand and that's all you were focused on. You gave your talk and the slides changed behind you. It was great. Now that I'm having to do this thing virtually, the webinar software that you're having to move between technologies, you're almost as much of an operator as you are a speaker.
It's impossible to focus while on both. The quality of the presentation is limited because I'm having to concentrate on technology. I would argue that it's probably the same in the medical profession, that you are beholden to this technology because you need to be able to chart, fill out forms, and everything that goes with it. You're so focused on making sure that you fill out the form correctly that you may not be listening or paying attention to the patient as well as you would want to. Am I off base? Is that a good way of putting it?
I don’t think so at all. It's a fantastic analogy and completely applicable to healthcare and your profession. It also represents an interesting period of time. If you look at healthcare technology as a whole, it offers the greatest promise of revolution and reformation in healthcare and also the greatest peril. These systems developed with good and positive intent but yet have transformed into glorified, super expensive, crazy cash registers. That's not right and that's not what we went into the profession for. Yet if developed correctly, if they continue to move forward in a positive manner, they have the potential of enhancing the provision of healthcare.
You're starting to see in the big picture of things, these are still early phase devices even though they've been around now many decades. They weren't initially developed with the clinicians in mind. They weren't necessarily initially developed with the patients in mind. They were developed for an easier exchange of information back and forth between parties, without an understanding of the purpose of that information. Now that you're seeing physicians become more involved as chief medical information officers, the user interface is focused on more than it being a cash register or a dashboard, but something that can potentially provide valuable diagnostic tools at the time of care.
It's got a lot of potentials. You're starting to see people dabble from a development perspective in simpler interfaces and virtual scribing, passive data collection systems where you're talking and that gets translated into it, but that is in the infancy, nowhere near ready for prime time yet. I would go back to your analogy of how much as a speaker that you spend time focusing on the technical tools required to deliver your message, that your message itself may suffer. The same thing has happened in healthcare. You spent time focusing on the input of data that the provision of your care suffers. In both situations, that highlights the importance of team-based care.
If you had somebody in the background handling your slides for you, handling the transition from platform A to platform B, or being able to get somebody online when they dropped off that you didn't have to do it yourself, your talk could theoretically be better. You could focus on what you're there for. You see the same thing in healthcare. Organizations are starting to become aware of that. Having scribes for providers in high flow areas, such as the emergency department, where someone's taking notes for them. This way, they focus on the emergency at hand. That technology needs to be developed that focuses on the provider and the patient, a benefit to them, not so much to the finance team or the compliance division.
Let's talk about the benefits of technology. Even if you're twenty years into this, we are still in the infancy of what it is because people in the medical profession now being involved in the research and development, and the creation of this software, it's going in a better direction. Has the level of software-enabled doctors to become better diagnosticians? Has it allowed them to be able to sit there and say, “The software realizes that because I input this, here are some things that you should be focusing on,” where it may be outside your area of expertise as a doctor, but it allows for the software to amalgamate and using AI or machine learning to be able to take all these data points and bring them together in far more cohesively than far more quickly? Are we getting there?
That's the incredible promise of this, a variant of predictive analytics. I don't think we're anywhere near it as of yet. The systems still present the providers what amounts to information overload and alarm overload that you're got to go through 50 checkboxes to get to the point where you can enter a note. You are barraged with data that doesn't have a coherent meaning to you as the provider or to the patient that you're seeing.
The future promise of this is what you described. I, as a provider, may be unaware of other external data points that are important. You're going to say to me often, “Yeah, doc. I'm taking your medicine,” but a system that integrates the information from your pharmacy that sees you do or don't get your prescriptions refilled and they aren't refilled on the appropriate schedule, could help a lot in me understanding where you stand in your care. The ability to see one-off lab values that I may be blinded to because of something that's going on that could be highlighted by a system, that makes a difference in your care as the patient. That's the promise. We're nowhere near there yet.
You brought something else up with scribe text. People that were following behind the doctors or the nurses and their sole job is to input the information into the system. Is the reason that isn't more prevalent is a dollar and cents thing? Is it the fact that we haven't got to the point where we understand from a CEO level the money that can be saved by spending the money to hire these people, the better care, the more efficient, fewer lawsuits, and everything that goes along with it that can be developed by having these people, doing their job and not having the physician taking time away from the patient or the nurse?Technology is becoming more ubiquitous in healthcare and carries a massive amount of potential for good. Click To Tweet
It's both of those things. For the most part, it's considered an incremental expense that does not return value. You got to pay for someone else to follow along, but the collections that are associated with that are no better, or there may be a little bit of an increase in productivity, but not enough of a margin to cover the expense of the individual. It's looking at a loss, “We can have the doc input their data. Why am I going to pick it up?” Even if I had someone doing it for him, there wouldn't be enough. It doesn't get paired enough with the value-based reward of if we do this, there is an opportunity to capture cost savings or accuracy or protection from a compliance perspective on some of those things even if it's filling out the bill correctly. There's a value associated with that, that the two parts of those systems do not get equal, “It's a good idea for us.”
Anecdotally, the areas that you tend to see scribing either technology used or actual personal scribes are high flow, highly reimbursed practices, areas per visit, the compensation is incredible. It's worthwhile to do even a little bit more of that or per visit. There's so much that is captured in revenue that if a little bit of that was taken off for the salary of the scribe, it makes it worthwhile. Whereas if you're in a lower output or a lower compensated system, it describes or deemed unnecessary. That's part of where I think the value of the technology enhancements can be. If it's something that's accurately done with a virtual passive system, that has the potential of scaling without an incredible increase in cost. If this has been building out the memory in a server and having additional licenses as opposed to having additional HR overhead costs, now there could be a value for a system to invest in it.
The technology is getting better to the point where they're working with the patient, the technology is scribing itself and all those types of things. It brings me back to the days where I used to hire a lot of salespeople. Salespeople are notoriously bad at inputting data. They want to be out, want to be with the customer, want to be in the hunt of things. When you tell them to come back and enter the thing into the system or invoice it properly, that's when the problems happen. I look at this analogy, our business became far more profitable when we hired admin assistance to handle 2 or 3 different salespeople. These three salespeople were making X amount of dollars at warranted one big person that could handle them.
The job was to tell the salespeople, “Come in. Tell the admin people what you did and then go away. Let the admin people handle it.” It made us far more effective, far more efficient, and far more profitable as an organization because we realized that different people have different skills. To utilize the skills of a salesperson to enter data into the system properly was not an effective use of time or energy. It was frustrating the salespeople because they weren't out doing what they should be doing. Those types of analogies need to be brought from different industries into healthcare to realize that, doctors, nurses, and all those types of things spent a lot of time building expertise within certain things and scribing may not be the most efficient use of their time and is not helping the healthcare system be better at what they do. Therefore, far more profitable.
You even see this reflected in my peers with the increased reported amounts of burnout and frustration with practice and desire to exit clinical medicine. It's because they're spending much time doing these administrative tasks that they're not passionate about nor are they effective about. It pulls them away from the things they want to do. It’s to provide care for patients who need it. It's the same analogy you made of the salesperson who sometimes with positive intent says, “I'm not entering that.”
Other times passively, “I can’t enter it. I'm doing other things.” That affects the overall results of the business. It’s like, “I got to enter that note.” He reports more and more, unfortunately, of docs choosing to do the right thing at the bedside and pay attention to the patient that's in front of them and do what it is. They're there to do and provide care who then have to take their documentation home and spend time away from their family into the early hours in the morning documenting the clinical visit.
How accurate is their documentation at 2:00 in the morning after they've seen 30 other patients?
It's a proven fact that it's less accurate. The most accurate documentation occurs at the time of occurrence. There is deterioration over time. It is natural. This is well-known, but the struggle between the two factors is real and it causing problems for individual providers.
What is the direction that you see things going? What's the positive than challenges and what should business owners and individuals be thinking about as they're engaging with the medical system moving forward?
There are lots of big directions in play that have great promise. Some of these technological enhancements that we've said. Traditionally, some portions of healthcare have been behind the curve. I would go to a local sandwich shop and order my sandwich on a touchscreen. In time, the production system in the back would make it and be handed to me. I would get a piece of paper of receipt and there's my sandwich. Yet to give you some of the most powerful medicines on the history of the planet, I would write it out, my scribbling handwriting on a 3x5 piece of paper, and hand it back to you. We did not adopt technology well in a lot of the parts of healthcare, but I think now it's more ubiquitous and growing as an integrated part of it with good purpose has a massive amount of potential.
The recognition of different methodologies of the provision of care and not the signs of the provision of care, but a focus on valuable preventative as opposed to potentially expensive and what could have been prevented technical measures later in disease are becoming more prevalent. The true concept of value-based care and understanding of high-value services and putting them at the forefront of care. A lot of docs are great at knowing “the why” of doing something and “the how” of doing something. Starting to focus a little bit on “the when” the appropriateness of doing it, “the where” is becoming a big part of it, “What's the best location for receiving care?” Traditionally, much of it was focused on expensive locations of care hospitals. How much of the things that are traditionally associated with a huge multibillion-dollar building could have been provided in the person's own home. There's a lot of that being embraced. It’s where the future of healthcare is.
The final point of the question that you asked there. At a business level, it has an incredible effect. I don't know the number off the top of my head, but in the US, 25% or 22% of GDP is spent on healthcare. That's a staggering annual cost. Quite honestly, it's unsustainable. Much of that cost is then born by businesses that are providing insurance for their employees. That can be a staggering and unsustainable cost to employers, then they're forced to make bad decisions. “Do we not provide healthcare insurance or substandard insurance for our employees and risk the downside to recruitment and staffing that will go along with that? Do we provide good insurance options for someone that then threaten the margin of our business and our ability to even exist?”
The third part that comes into play is neither of those considerations takes the patient. This analogy, the employee in mind that if your employee were to leave your company and go to another company for potentially good reasons, something you'd be proud of a promotion, a better opportunity that you've developed, and they're moving on for a great role, they could lose their insurance or something that they previously were taking care of is now considered a preexisting condition. The new part that the insurance benefit is tied to the employer and not the patient. It doesn't follow them along. That starts an entire poor cycle of costing, mistaken cost analysis of the care of that individual that causes a lot of problems for the system as a whole. That needs to be addressed at truly a system-wide level.
It sounds like there are many challenges, opportunities, refocusing and I don't think we're going to be able to solve all these things in one conversation, but I truly appreciate the insights because it's things that many people are not paying attention to. It's hidden costs that people truly don't understand of different ways that they can use preventative medicine within their businesses, their personalities, and the organizations that can save them an enormous amount of time, energy, and cost in the long run. One last question. When you leave a meeting, you get in your car and drive away, what's the one thing you want people to think about you when you're not in the room?
I hope that in some way, shape, or form, I had a positive effect in their life that they realize that maybe they didn't agree with what I was saying, but it was being said for the right reasons to benefit the team, the group, the other individual. That someone might be able to say, “He looks out for us,” would be a fantastic thing to hear. I'd love to be a fly on that wall.
Michael, thank you for all the insights and your passion for what you do to the people that you help and you serve every day. Thank you for everything. I truly appreciate it. I'm sure my audience has gotten as much value out of this as I have.
We may not have all the solutions. I appreciated the opportunity to highlight the problems. Thank you for having this talk.
As a physician executive, I provide vision and innovative solutions. My goal is to help organizations improve patient care and financial outcomes.
Currently, I’m the Chief Medical Officer of Trellis Supportive Care. I’m well respected by my peers for achievements in strategic planning, financial management, and new program development.
I am relentlessly curious, I’m adaptable, and I deliver. These qualities are invaluable in my life and my career.
The advanced communication skills I’ve developed as a hospice physician serve me well as an executive. They help me listen, clarify, and effectively address critical issues.
I’m also a passionate foodie and chef. Cooking was always a shared hobby in my family when I was a kid. Now I’m thrilled to continue the tradition with my own family. Get to know me well enough, and I may share my prize-winning pastrami recipe with you.
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