ChalkTalkJim: Breaking Down the Game - A Guide to the Future of Healthcare

The Logic of the Heart: How Dr. Scott Roth Co-founder, CEO, and CMO at ImaCor Found His Calling in Cardiology

March 22, 2023 James Jordan Season 1 Episode 4
The Logic of the Heart: How Dr. Scott Roth Co-founder, CEO, and CMO at ImaCor Found His Calling in Cardiology
ChalkTalkJim: Breaking Down the Game - A Guide to the Future of Healthcare
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ChalkTalkJim: Breaking Down the Game - A Guide to the Future of Healthcare
The Logic of the Heart: How Dr. Scott Roth Co-founder, CEO, and CMO at ImaCor Found His Calling in Cardiology
Mar 22, 2023 Season 1 Episode 4
James Jordan

The physician's role is changing, and here’s a cardiologist’s perspective on what’s coming down the road.

In this episode, Scott Roth, co-founder, CEO, and Chief Medical Officer at ImaCor, questions the current medical education system with a full-circle conversation based on his experience in cardiology, the transition to team-based care with a value-based model, and the evolution of noninvasive imagery technologies. Healthcare industry incentives have changed in the past decades, and so Dr. Roth discusses how motivation is a challenge that should be addressed by the educational system and supported with a value-based model.

Tune in to learn more about the evolution of echocardiology and the role of physicians in healthcare!

See More ChalkTalkJim Episodes

Get more information on Healthcare Data Center.

Show Notes Transcript Chapter Markers

The physician's role is changing, and here’s a cardiologist’s perspective on what’s coming down the road.

In this episode, Scott Roth, co-founder, CEO, and Chief Medical Officer at ImaCor, questions the current medical education system with a full-circle conversation based on his experience in cardiology, the transition to team-based care with a value-based model, and the evolution of noninvasive imagery technologies. Healthcare industry incentives have changed in the past decades, and so Dr. Roth discusses how motivation is a challenge that should be addressed by the educational system and supported with a value-based model.

Tune in to learn more about the evolution of echocardiology and the role of physicians in healthcare!

See More ChalkTalkJim Episodes

Get more information on Healthcare Data Center.

[00:00:01] Jim Jordan
Welcome to the Chalk Talk Jim Podcast, where we explore insights into healthcare that help uncover new opportunities for growth and success. I'm your host, Jim Jordan.

[00:00:18] Jim Jordan
Our guest today is Dr. Scott Roth. Scott, tell us a little bit about yourself.

[00:00:22] Scott Roth
Thanks, Jim. Really appreciate being on with you here. So my background is as a physician in cardiology and specifically noninvasive cardiology. Actually, I grew up in New York and started out as a volunteer, sort of knew that I wanted to get involved with for whatever reason, but I was really the first one in my family to go beyond college. And so, I got involved very early on as a volunteer in some of the hospitals in New York, even in high school. And then when I arrived in Boston for college, I immediately went to one of the hospitals there and volunteered and started out pushing wheelchairs and moving blood samples around, essentially.
And that subsequently led to some relationships where I ended up as a student doing biochemistry research and then subsequently medical school. I can tell you about some special stuff that we did related to my particular medical school experience. So I actually went to college, and med school at BU, Boston University, took a somewhat non-traditional path. There were multiple programs at BU, there was a very special new experimental program which was called the MMedic Program, Modular Medical Integrated Curriculum. I was one of only about 15 people in the first group. What that meant was we actually took some of the first-year med school courses in the second and third years of college. When we got to the first year of med school, we had already taken biochemistry and microbiology, so we had blocks of time to do things that others had never done in med school. As an example, one of those was an interviewing course where we were videotaped and learned how to interview patients, and another was I got hooked up with a cardiologist in his outpatient office in Milton, Massachusetts, and the two of us, sitting in his office, using stethoscopes, and sitting down and having a Diet Coke after each patient and talking about it is what got me into cardiology. That was also my first introduction to cardiac ultrasound. I hesitate to say how long ago this was, but it was at the very beginning of cardiac ultrasound, and this particular cardiologist who was in private practice solo, had an early form of cardiac ultrasound in his office, and that's where I really got my first exposure and got into cardiology and cardiac ultrasound as a medical student.

[00:02:47] Jim Jordan
Let me pause again and make sure I take all this in. So during medical school you were drawn to the logic of the heart, and you felt the system was extraordinary in the sense that no man-made mechanical system can really work that long. And finally, there was a long history of innovation, which meant that you would have the tools to do something about the problems you saw in your patients. So that was medical school, and how long was the road after that?
[00:03:12] Scott Roth
One of the things that attracted me to cardiology in the first place is, as you said, it's a very structured, organized system that, for the most part, you can figure out what's happening. Like you said, there's plumbing and pipes and pumps and electricity and an overall purpose. So that was, that's one thing that's attractive about it. I never liked memorizing in school, so I found that cardiovascular issues, you could reason it through. And as I said, when I first started to learn from a solo cardiologist in his office, the two of us would sit and discuss these issues for patients. At the same time, there's a greater than 100-year history of cardiology and cardiovascular disease. And the other thing that attracted me to cardiology is its importance in that you can't really do much if the cardiovascular system is not doing its job. And one of the things that fascinated me from day one was that the heart is working 60, 70, 80 beats per minute, but it's every second, every minute, every hour of your life, and if it doesn't do that for 3 to 4 minutes, you don't make it. So this is extraordinary. How could, as you said, an electrical mechanical design system work continuously for your entire life? There is no man-made system that's capable of doing that. So I thought those two things are fascinating. And then the third thing is that what's unique about cardiology during this period, it really is about a 40-year period, let's say that, what's unique about it is that not only can you figure it out, but during that period of time, tremendous progress was made in both diagnosis and treatment of cardiovascular pathology and pathophysiology and disease whereas in some other fields it's taken a lot longer. So as an example, I was doing a rotation in med school, and you get exposed to multiple fields, and on my neurology rotation, I learned that it was fascinating, very complicated, and then when we saw a patient on rounds, and we learned from the attending physician that we had figured out what was wrong with the patient, I turned to the attending physician as a student, and I said, okay, what do we do now?
And he looked at me and said, well, nothing. We can't do anything, we can't treat this. And I realized that that moment, that there are some fields that are further along than others in terms of both understanding the tools and the treatments and we could do something about heart attacks and heart failure and arrhythmias. And actually, during this period of time, 30, 40 years, there's been just tremendous progress in treatment in cardiovascular disease. Certainly, other fields have moved along that period, but cardiology has actually been pretty early in having very useful tools and having an impact, honestly, in morbidity or mortality.

[00:06:12] Jim Jordan
What's next after medical school when you go into a specialty like yourself?

[00:06:15] Scott Roth
Yeah, that's right. It's actually a pretty long road many people may not be aware of, but as you said, medical school is, in the United States has been broken down into two phases. The first phase is didactic and classes and learning the foundational principles of anatomy, physiology, and such, that's the first two years. The second two years are clerkships. So as I described, you then get exposure over the second two years, and during that exposure, you're asked to choose for the next phase, which area would you like to concentrate on and focus on. And so the next phase after graduation from medical school is typically an internship and residency fields. Funny story in terms of how I made that decision, one of my other rotations was in cardiac surgery, and I thought it was the greatest thing in the world. I was blown away by what these guys were doing, but working in the operating room with these guys, I realized it's not something I can do to stand there for 12 hours and hold a retractor and never get any sleep, etc. And even though I was fascinated by the capabilities that they were developing, I decided at that time to go on the medical side. And so the pathway to cardiovascular specialty on the medical side is you first need to do an internal medicine internship and residency, which all told is three years. And so I'm an internist as well, first, I have to become an internist, and there are multiple subspecialties then from internal medicine, and cardiology is one of the subspecialties of internal medicine. So you do one year of internship, two years of residency, which I did in the Bronx and New York. Then you do typically three years of cardiology fellowship after that. So four years of med school, three years of residency, three years of fellowship. And honestly, I've trained many residents and fellows, and even at the end of fellowship, they're still not really considered an experienced clinician. And these days, as cardiology has developed further, there are subspecialties that take even longer. In particular types of interventional cardiology or electrophysiology, or some of the imaging subspecialties have gone even further than the three years of fellowship.

[00:08:37] Jim Jordan
Can we do some math here? So becoming a doctor sounds like it takes a lot of time and money. You need a four-year undergraduate degree, then four years of medical school, followed by three years of residency, and more than three years of training in your chosen subspecialty. And in some cases, like cardiology, it's even longer, so that's like 15 years. And assuming you entered your bachelor's degree at 18 years old, you're now 33 years old. So can you share some economics about how you earn money during this time?

[00:09:06] Scott Roth
Yeah, it was very challenging, I would say. For med school, I was helped out by scholarships and my family, and then, but still had some debt, not as much, I would say, as students have today. Today they probably have on the order of hundreds of thousands of dollars. At that time, it was more tens of thousands, I would say. And what I needed to do then, in internship and residency, our salary at the time was $23,000, and I was married, and there really wasn't a lot that you could do living in New York on that amount of money, even at that time. And at some point, actually, I came home, my wife wanted to have children, and I had said no for a long time. And then one day I came home, and I said, you know what? I have seen everything. So much disease and people issues, etc, so let's just do it, and we actually ended up having our first child toward the end of my internal medicine residency. So throughout that period, in order to survive, I moonlighted. That was a very common way of trying to pay off student loans and surviving.

[00:10:15] Jim Jordan
So let's move forward a little bit. You complete your cardiac fellowship. What did you do next?
[00:10:20] Scott Roth
Their, medicine residency, I did a cardiology fellowship which took, again, about three years, and so I ended up on Long Island, and that's where we ended up living and working and practicing. My particular choice was, because I had been exposed to cardiac ultrasound very early, that was an interest of mine. And so I ended up doing work and urgent teaching and patient care centered around cardiology and cardiac ultrasound. So I stayed on at the hospital on Long Island and took a full-time faculty position. So I wasn't in private practice at that time, but I was full-time. And at that time, sort of relevant to the healthcare landscape, if you will, we had what we called the three-legged stool, which was patient care, teaching, and research. So our days and nights were filled with those three things. We did a lot of training about physicians, a lot of lecturing and teaching, and rounds, but at the same time we had direct patient care responsibilities. So I was the director of the echocardiography lab at that hospital.

[00:11:26] Jim Jordan
Now, what disease would you be looking for with the ultrasounds?

[00:11:29] Scott Roth
Yeah, that's a good question, actually. The capability of cardiac ultrasound actually evolved during that period, and as the capabilities of the technology evolved, our ability to diagnose and manage a variety of cardiovascular diseases also evolved. So as you mentioned, you have heart muscle and pumping function, they have coronary artery disease, and perfusion of the heart muscle. That's a sort of number one, right? That's the cause of what's related to heart attacks. And in addition to heart muscle, pumping function perfusion of the heart muscle with coronaries, then you have the valves, and around that you have the more mechanical stuff going on, like around the heart, heart sits in a sac called the pericardium, and then everything is connected to the vascular system, so you also have to evaluate the arterial tree, in particular the aorta, which is the largest artery coming out of the heart. The same is true for the blood coming into the heart from the lungs, so you have the pulmonary circulation as well. And so during that time, there was a tremendous evolution of cardiac ultrasound technology. So at first, we were only capable of really looking at heart muscle function and rudimentary assessment of the valves, initially, because we were only able to take pictures. During that time, the technology evolved to the point where we also then had the ability to measure and look at blood flow, and we started to get better at evaluating valvular heart disease and actually being able to measure flow and pressure. The reason that's relevant is that we stood side by side with the other aspects of cardiology, one of which is the cardiac cath lab. I don't know if you're familiar with how that functions, but Cath lab stands for Catheterization Laboratory. So most of the 100-year history of cardiology prior to this was focused on pressure and flow measurements using catheters that we would put literally into the heart. I was in a very unique position in that my echo lab, a reading room, was adjacent to the cardiac cath lab in our hospital, and I was amongst the first group of cardiologists to learn from the cath lab directly. So we compared directly at that time as the technology was evolving, how well am I doing? And the cardiologists who were older than I was were focused on figuring out things like valve disease through catheters and initially didn't believe that we could do the same thing through cardiac ultrasound now that we had these flow and pressure capabilities. So that occurred not all at once, but over a period of time.

[00:14:13] Jim Jordan
So normally at this time in the interview, I'd ask you a question about a time when you have adapted or shifted strategy, and it seems fortuitous that having your office next to the cath lab allowed two subspecialty teams to work together. And when I look at your career, and I listen to this interview, it seems to me also that cross-disciplinary curiosity and teamwork has been your approach since the beginning as a medical student. We talked earlier about the importance of cross-disciplinary teamwork to create change. However, there also needs to be a big problem to motivate going from one gold-standard to the next. So can you share a bit about the evolution and the big problem that was the tipping point for this change?

[00:14:49] Scott Roth
That's a good question. So these things evolved along multiple pathways. So one pathway had to do with increasing capability, our capability in the cardiac ultrasound laboratory, which we called the Echo Lab at the time. Our capability was increasing dramatically, so much so that it started to either supplant or subsequently replace the measurements that we were doing in the cath lab. One striking example that actually then relates to what I focused on, which is a specific form of echocardiography called transesophageal echocardiography, where we could get a different view of the heart instead of from the surface, from the chest, where we would put ultrasound on the surface and look in, we could also be specialized tube like an endoscope into the esophagus. And just anatomically the esophagus is immediately behind the heart, so you get really good pictures, and you get a different view. So I was also involved with that very early on, and so one example of gold standards changed very quickly in that situation. So one disease state that we had seen was aortic dissection, which sometimes you'll hear in the news if a famous person dies suddenly and they figure out this was an aortic dissection, very difficult to diagnose, essentially, and if you don't diagnose it quickly and treat it quickly, the patient doesn't make it. The gold standard for assessing the aorta in that situation forever was the cath lab, so the surgeon would not bring the patient to the operating room without an assessment from the cath lab was called an aortogram that you would inject dye into the aorta, and see where a tear had occurred. That was the way things were done.

[00:16:33] Jim Jordan
Knowing a little bit about this, that is a big loss of time.

[00:16:35] Scott Roth
Yeah, big loss of time, and exactly, that's a very astute observation. I can remember specific patients in the emergency room where our clinical assessment was. I think this is what's going on. I would speak with the surgeon as the medical cardiologist, and if it was 2:00 in the morning, as you just said, that meant that we had to call in the cath lab team and proceed from there before we could take the patient to the operator. It was a tremendous loss of time.
[00:17:03] Jim Jordan
And I think of a tear as having two aspects to it. The first, it can block the flow, but it could also pop into an aneurysm and burst, correct? And rupture.

[00:17:12] Scott Roth
Yeah, and they do.

[00:17:13] Jim Jordan
And then game over.

[00:17:14] Scott Roth
Yeah, game over, and this all happens very quickly.

[00:17:18] Jim Jordan
So now you're talking bring the people in, get the cath lab going. Are you talking two hours, perhaps?

[00:17:25] Scott Roth
Hours, yes, you're talking about hours. And so sometimes we were not successful, honestly, and by the time we got to the operating room, if we got there at all, it was too late. So what was happening during that time is three other methods were being looked at to assess this part of the cardiovascular system, the aorta. One was MRI, which was very new, wasn't really clear how good it was going to be. The other was CAT Scan, which was being done more frequently, and the third was Transesophageal echocardiography, which I happened to be involved in very early. And so what happened is, all started looking at this, could we do this better with noninvasive methods? Not the cath lab, not an aortogram. And as it turned out, what we were doing and what others were doing, the transesophageal echocardiography was just a beautiful solution. We could do it in minutes, you knew right away if there was a tear or not, you also, the other major advantage, which you did not have from the other methods, was one thing that the surgeon needs to know in addition to is there a tear, yes or no? How bad is it? Yes or no? They also need to know are there complications? We could determine that with cardiac ultrasound and transesophageal echocardiography literally within minutes, and also we could do that at the bedside. We could bring that equipment to the emergency room and figure this out very quickly. There was a period of time where the cardiac surgeons didn't believe it and initially required that we do both. They wanted the cath lab and the aortogram, and directly. And then one day no one ever did another aortogram for this particular problem, and the gold standard changed like that. That's how it happens.

[00:19:09] Jim Jordan
So you and I have decided to break the interview into two parts. And as a teaser for part two is a discussion on how you have used Transesophageal Echo to create the next gold standard. But what I want to do is to continue our discussion on physicians. What kinds of issues are you seeing?

[00:19:25] Scott Roth
I'm an optimist at heart. Can we get back to the doctor-patient relationship and sort of the satisfaction with practicing medicine? I think the answer is we don't go backwards, we can only go forwards, and it gets different.

[00:19:39] Jim Jordan
So ironically, the story seems similar to the evolution in the time it takes to create a new gold standard. In the past 30 years, we've gone from private physician practice to physicians that are joining groups or becoming employed, and they have less time with the patient, more administrative time, and yet the reimbursement system is misaligned with these changes.

[00:19:58] Scott Roth
And I tend to think of this as a landscape. I think the shift that we're undergoing, from a physician perspective, is a change in the role of the physician. There was a time when the physician-owned their individual practice and had total control over the incentives and sort of what they did. But as the landscape has evolved, that's not really possible anymore. We sort of have to ask ourselves, where have we been, where are we now, and where do we go? Now, I think we're in this phase of moving to team-based care. So we see that in inpatients and for procedural specialties, like cardiology or surgery, but I think we also see that in a different way for primary care and outpatient care. Both are, in my opinion, now characterized by team-based care. So meaning that the physician may be the leader of a team, but there are other team members who are also clinicians who are interacting directly with the patient. And as you said, we as patients are experiencing that there's less time available with the physician. What's happening, I think, is that the physicians will be fewer in number, but leading larger and more complex teams.

[00:21:15] Jim Jordan
And for the audience, I have an academic website called Healthcare Data Center, and as I sent you some of my data prior to our discussion, some of this data supports your statement. The American Medical Association has data supporting these changing dynamics. In terms of physicians entering the workforce over the last decade, female physicians have grown 46%, compared to 10% growth in men. Also, the majority, 55% of solo practices are owned by older physicians, and almost 70% of physicians under 40 are either employed or part of a subspecialty group. Since you travel the country and spend time with so many physicians, do these younger physicians have different expectations or wants than your generation?
[00:21:57] Scott Roth
I think that the young people coming in are very smart. They understand what's going on to a certain extent. They haven't yet had the experience living inside the system, but at least in talking to people, I believe that they recognize that this is not your father's Oldsmobile. They are not doing what we were doing 20 years ago. There's evidence of that from a number of different perspectives. One, as you mentioned, is that the vast majority of physician arrangements are employer-employee arrangements. I think that's emblematic of this shift, that's one that really tells you the story. And so young people coming in, their expectation is that they will be employed. That's a dramatic shift. What we used to think of as private practice was really self-employment.

[00:22:47] Jim Jordan
And attractive to you as a young physician.

[00:22:50] Scott Roth
For me, it was, because I grew up in a small business family and to a large extent, the concept of charge of your own destiny had advantages, were great. And so when I grew up in a small business group, what I heard at the table every night was we had a good month, we had a bad month, but at the same time you were in charge of your day-to-day and your interactions with patients. The relationship of an employer-employee is very different than self-employed for physicians. I think that's the sort of first sign that you can see, to answer your question, you know, what do young people think as they're coming in and going to medical school? And then, like you said, looking at sort of years of training, what are they looking at as the end state? The end state is you are an employee. The question is, how does that shake out in terms of your lifestyle, etc? The best way that I can think about it is I think it's very different for primary care versus specialties. And so primary care is shaking out in one way, and specialties are shaking out in a completely different way.

[00:23:55] Jim Jordan
In what way are they different?

[00:23:56] Scott Roth
I think that both are experiencing a shift to team-based care, but the teams look different, the teams are run differently and have a different purpose, and are populated with different people. So if you take the specialty care, cardiovascular disease is one where you have cardiologists and cardiac surgeons, these are procedural specialties to a large extent. And as you mentioned, the payment system is such that it's paid by procedure or fee-for-service type system. That's difficult to change in the specialty areas because it takes a lot to do heart surgery, transcatheter valves, it requires a lot of capability, and it's expensive and difficult. So those teams have evolved to the point where they're multidisciplinary teams that exist inside hospitals to a large extent. And so we can talk about sort of the control of those teams and how the money flows and such, but they have to do a significant number of procedures in order to maintain their capability, their quality, but also their income. The outpatient side of primary care, it doesn't look like that at all. It doesn't take the same type of technical and expensive specialized capability to form the team as an outpatient primary care, seeing broad groups of patients. But at the same time, it's actually difficult to put those teams together because the physician alone can't do it by themselves any longer because the numbers don't work, they don't get paid enough. When you talk to primary care physicians, they may have to spend half their time on the electronic medical record or be doing patient charts, it's not a sustainable way of doing things. So I think what's happened on the outpatient side, you know, one place to look is, I think retail healthcare is actually a good example of this. On the back end, you have arrangements of aggregating the patients, kind of bringing them in, and Medicare Advantage, etc., and so primary healthcare becomes team-based. The physicians are employees, but they're running a larger team with nurse practitioners, medical assistants, etc. And these two areas, outpatient primary care teams, inpatient specialized capability, procedural specialty teams, I think are the way that this is going to evolve.

[00:26:18] Jim Jordan
You made me think of something that I really never thought of before. All physicians have to use their minds continuously to maintain their mental dexterity. However, it seems to me that the specialties and specifically surgeons are like athletes that need to practice to maintain their physical endurance and their muscle memory. I think this is good insight for administration and good insight into thinking about how much administrative burden we put on these specialty areas.

[00:26:43] Scott Roth
I think it's evolving. As I think you may have mentioned, value-based care is the future. I think everyone can see that, but how value- based care is implemented is very complex and not well worked out yet. And so in my opinion, what we're seeing is that some of the methods of value-based care apply and are being used in primary care. So Medicare Advantage is a good example of that. It's essentially based on some old methods that were argued about and not agreed upon or actually happening. And one of those methods is called capitation, where the payer, in this case, Medicare, pays the providers a fixed amount, and it's up to the provider group to figure out how to use that fixed amount to do the job and take care of the patient and get better outcomes and such. That does not work well or has failed in the more complex inpatient areas like heart surgery and stents and valves and such, it's more difficult, so I don't think anyone knows the answer.
[00:27:47] Jim Jordan
And so I'll try to impart one here with just a final question. I sent you some data, and the American Medical Association is talking about physician shortages, anywhere from 40,000, 124,000 physicians by 2034, and then I sent you some data that showed we're going to have an overabundance of nurse practitioners and physician assistants. And so it seems to me, your first thought is, well, let me make more physicians. Well, it takes 12 to 15 years to make more physicians. And the curious thing is, when you look at the baby boomers, by the time you would start to get the demand back up, they're all going to be expired, and you're not going to need that many physicians, and now you've put extra physicians on the market for 30 or 40 years. So at first, I was, why are we capping this? And now I sort of get it, I think. So it's inevitable that the math is going to make these physicians become the coach of the team and that nurse practitioners and PAs can do more tactical stuff, but I guess we just don't know how that's going to play out.

[00:28:45] Scott Roth
And so where we've been, we understand, right, it was doctors and patients. Where we are today, team-based care is the rule, they're developing. I think they're developing differently in the outpatient primary care world and the inpatient procedural world. I don't believe in the pendulum. I don't think there is a pendulum. I don't think it swings back to where we were. I think it goes to a different arrangement. The only way this is going to work going forward is if physicians are running teams and obviously, in making clinical decisions and performing procedures. And so on the outpatient side, yes, more NPs, no question about it, some are running their own club teams. And on the inpatient side, we've seen this. In intensive care, there was a plan that hospitals had about ten years ago that they were just going to hire more physicians to run ICUs, intensivists, or physicians who specialize in intensive care, and that plan really didn't work. The work itself is too complex, too diffuse, too difficult, and you just cannot put enough doctors into that to make it work, and what they discovered was it actually works better with more diverse teams. So when you go on rounds now the ICU, which I've done continuously and recently, you'll have a physician leader, you'll have multiple nurse practitioners or physician assistants, you have staff nurses, and at the same time on rounds, you'll also have the pharmacist, and you'll have the respiratory therapist in the same group and some others. So I think where we're going is specialized teams on the one hand for specialized procedures, and then broad-based teams around patients and primary care groups.

[00:30:33] Jim Jordan
So this brings it back around to your Boston University program where they were teaching you how to interview patients and how to do some different things. Do you see curriculums in medical school changing to incorporate this new environment, or is it yet to change?

[00:30:48] Scott Roth
I think it's not there yet, at least from what I can see the school's in a transitional period. Like you said, the demographics of who's coming in is somewhat different than it had been in the past. What it is that needs to happen during medical school is clearly changing, but I don't think the story is completely written yet. So you do see some healthcare delivery classes and things like that, and some of this is really more public health than anything else. So where a clinician, doctor, or patient fits in, I think it's clear that it's a smaller part of what they're going to learn in medical school, and it's a smaller part of what they're going to be doing in their professional lives going forward.

[00:31:28] Jim Jordan
Having been involved in adult education, in industry, in universities, it's an expectation that schools are producing people that have a certain skill set, and these other broader skills are expecting the businesses to train them on after they've graduated. This strikes me that this is what care is going to have to do. I don't know if you can reduce their education by years to accommodate these other business and information management skills, I think we're going to have to train them in industry. I'm not sure if I came up with this term, I read it somewhere, so I'm not going to claim it as my own, but it was talking about Return on Intelligence. So doctors, obviously, some of the smartest people that we have in this economy. And so the question is, if you were a purely logical thinker for return in investment, with that intelligence, you can make a lot more money doing other things that are way easier. So that's one argument about going to have less physicians in the future. On the other hand, I have never quite met a physician and got to know them and not find out that it was in their blood. What's your thought?

[00:32:32] Scott Roth
So, that's right, so I think you sort of hit the nail on the head. The challenge going forward has a lot to do with motivation. What is your motivation to become a professional? And as you mentioned, lifestyle, money, taking care of your family, that's one motivation, right? But as you just said, in patient care, medical areas, that's not the only motivation. So I've always believed and have lived it myself, that people who spend their time in medicine or in clinical areas get up in the morning for many reasons other than making a living, and there are diverse reasons like having an impact and helping patients, your fellow person, etc. But the question is, how do you gain that? In the sense of doing well, by doing good at the same time that the system is shifting so dramatically, the role of the physician is not what it was. How do you do that? And so to a large extent, I agree that the problem to be solved is, how do you move these pieces around and maintain the clinical, medical, taking care of the patient aspects at the same time as attracting the best and the brightest to do that, where they're not completely in control of the situation, and they may not be making as much money as they did in the past? How do you do that? I think that's the hard part.
[00:33:57] Jim Jordan
So let me try to wrap up here, Doctor Roth, I thank you for your time and your insights. As this discussion is for the broader healthcare audience, regardless of where you are in the health system, I think we all agree that the US healthcare system is one of the most expensive in the world, and yet our quality does not often even rank in the top ten. And as Doctor Roth stated, the future is value-based care that has to be implemented well, and there are many details to work out, and it's clear that team-based care must accompany value-based care, yet what does this mean for our education system, given the limited hours that we have to train physicians? Are we served well by adding administration and information system training to their curriculum? I personally feel that's not reasonable, given that in the future we're going to have to add training on robotics tools and artificial intelligence, and other technology tools that improve clinical care. I think adding these skills is going to be something that the employer must invest in, and in fact, at Carnegie Mellon University's Heinz College, they have developed a master's in medical management specifically for physicians, and often these physicians are sponsored by their healthcare institutions, recognizing their responsibility in this area. In terms of implementation concerns to team care, it has increased physicians' time away from the patients, often decreasing their reimbursement opportunities and increasing their administrative burden and job dissatisfaction. And the challenge is, given our return on intelligence discussion, physicians often enter the field for its satisfaction, not its return on investment. Dr. Roth's insight on the rigor of being a specialist and a surgeon was also very informative to me personally. He commented that they're like an athlete and they need constant practice to maintain capability and skill, and I thought, is an unintended consequence of our system change that we're intentionally reducing the skills of these people by drawing them into administration? Dr. Roth's insight left us with the challenge, How do we thoughtfully implement value-based care and get back to the satisfaction of practicing medicine? Dr. Roth, I thank you for being our guest, and for all those listening to our podcast, thank you for contributing to the challenge of improving our healthcare system.

[00:36:07] Jim Jordan
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