October 16, 2018, 04:15 pm David Mitchell New Orleans – There was a time, briefly, when it looked like Zubin Damania, M.D., had health care 3.0 figured out.
Damania's Turntable Health was a direct primary care practice in Las Vegas that brought doctors and nurses together with social workers and health coaches to provide prevention-focused, team-based care in an innovative setting that included a teaching kitchen and a teaching studio.
In one year, the practice cut emergency room and inpatient admissions in half. Ninety percent of patients said they would recommend the practice to others.
"That's unheard of in health care," said Damania, the physician, comedian and rapper who performs under the name ZDoggMD, during a main-stage presentation, which also featured his music and videos, Oct. 10 at the Family Medicine Experience. "We were doing things for people instead of to them. We were available to them even in middle of night, but we didn't get that many calls because we had already handled a lot of it in clinic."
During an era of staggering rates of physician burnout, Damania said the experience was transformative for patients, as well as physicians and staff.
Zubin Damania, M.D., the physician, comedian and rapper who performs as ZDoggMD, speaks during the Family Medicine Experience. Damania was the featured speaker Oct. 10 in New Orleans.
"It wasn't easy. It was hard work, but here's the secret about us," he said to a massive hall filled with physicians. "We will work as hard as it takes when the work is meaningful. We will work long hours. We will sacrifice our 20s when the work is meaningful. When we're doing someone else's dirty work, clicking boxes, that's not meaningful."
Despite its successful patient outcomes, Turntable closed roughly three years after it opened when partner Nevada Health Co-op folded.
Damania said his vision for health care 3.0 is still to have adequate time with patients and the kind of autonomy he witnessed in his father's primary care practice, mixed with the potential that the tools of the current health care system hold to reduce medical errors, increase efficiency and reduce duplication, and an electronic health records system that could "teach us the story of our patient and get out of the way so we can care for them."
Such a health care system, the internist said, should pay primary care better and focus on disease prevention.
The sad reality, he said, is that our country is stuck somewhere between health care 1.0 and 2.0. He likened the 1.0 of his father's generation to a shore and the current 2.0 to a boat with an unknown destination.
"Most of us have one foot on the shore of 1.0 and a foot in the boat," he said, "and the crotch is ripping down the center."
Damania grew up in California dreaming of becoming the next "Weird Al" Yankovic. As the son of two Indian physician parents, however, the pursuit of being "a professional clown" was not encouraged.
Instead, Damania drew inspiration from the relationships his father built with a largely immigrant, Spanish-speaking population.
"He would see the Medicaid patients and the disenfranchised, and they were fiercely loyal to him because he was about touch, intuition and relationships, and not about click, click, click and ordering tests," he said.
When Damania told his father he wanted to follow him into primary care, his father discouraged him and instead told him to follow his uncle into gastroenterology.
"There are $5,000 rupees in everyone's colon," his father said. "Do the fellowship in GI, get a scope and fish it out. Look at your uncle. All day, his patients are unconscious in a prone position, and he is playing video games inside the buttocks. Look what he is driving. Lexus. All day I hold hands, build the relationships, do home visits, fill out charts, I'm on the phone with prior authorization nonsense. What am I driving? A Camry with fabric interior."
Damania wasn't dissuaded and spent a decade in outpatient medicine at Stanford University before moving to Las Vegas.
He said that for all the folks who wax nostalgic for the good old days of paper charts, health care 1.0 had its share of flaws, including less emphasis on evidence and a lack of randomized trials, illegible charts, fraud and a fee-for-service system that emphasized procedures rather than prevention.
Health 2.0 has its own troubling flaws and has devolved into what Damania dubbed the "Measurement Industrial Complex."
"We were promised technology that would save us from ourselves -- improved handwriting, improved outcomes, data, artificial intelligence," he said. "How has that worked out for us so far? We were promised an iPhone, and we were given a 1990s car phone. You're thinking, 'This is great,' but then it has a rotary dial, it drops its signal every block and it costs $20 a minute."
Damania demonstrated the complexity and onerous requirements of the current system with a mock visit with an unlikely patient -- Winnie-the-Pooh.
"He's adorable until he's patient No. 30 … out of 35," Damania said. "And it's 4:39, and he shows up for a new patient visit."
Damania presented a detailed diagnostic rundown of the fluff-stuffed bear.
"Mr. Pooh, I see an anxious, concerned facial aspect. That's ICD-10 F41.80 -- anxiety with depression," he said. "Wait, I also see a black, necrotic nose, so let me update that ICD-10 to 14.180 -- cocaine abuse with induced anxiety."
It gets worse. The patient's protuberant abdomen and lack of fingers and toes indicated diabetic neuropathy with autoamputation.
"And despite Mr. Pooh's name … he hasn't. Constipation," Damania said. "And despite his litany of glucose-related metabolic effects, Mr. Pooh presents to your clinic with his autoamputated right paw deep in a jar of honey."
At this point, he said, the physician has less than 25 minutes to address all these issues.
"I say, 'Mr. Pooh, what are your allergies and medications?'"
"Oh, bother," the bear responds, "isn't that in your computer?"
"Yes, Mr. Pooh, I'm sure it's in the Epic unit at the urgent care you go to across the street," Damania said, "but it doesn't talk to this Epic unit in the clinic."
The doctor then explained the diabetes diagnosis and offered advice on diet and exercise.
"Let's be blunt, Mr. Pooh, you're fa …" Damania began.
"Actually," Damania said to the audience, "don't use the F-word with Mr. Pooh because he will rip you a new one on Healthgrades."
Exercise more and eat less junk, he advised the bear. But the patient, Damania said, also needs medications, subspecialty referrals, tests, a glucometer and scheduling for surgery and followup.
"Click, click, click, click, click," said Damania, pretending to type on a keyboard. "Mr. Pooh is like, 'Oh, bother,' and walks out the door. He gets around the corner, and you get a pop-up on your screen."
"Hey, yo, Pooh, don't smoke, bro!" Damania shouted down an imaginary hallway.
"That's 99406, smoking cessation counseled," he told the audience.
Doctors, of course, don't really get to take care of beloved cartoon characters, but the complexity and documentation requirements are real.
"That is our world right now," he said. "This is why we have burnout. How are we going to fix it? I'm looking at the people who are going to fix it. You guys are on the front lines every day doing this work. If you don't fix it, ain't nobody going to. Worse yet, they're going to fix it for us."
Damania said his exam rooms at Turntable featured large, flat-screen monitors mounted on the walls so physicians and patients could view and discuss charts together.
"What have we lost in health care 2.0?" he asked. "We've lost human touch, laying on hands, looking people in the eye -- the stuff that actually heals. We've lost the patient."
But Damania found Pooh again, this time in the ER. The patient wasn't compliant with his meds and he had skipped a followup appointment.
"They look at his glucometer," Damania said, "and it just says, 'OMG.'"
Making matters worse, he said, is that burned-out physicians at hospitals may be openly hostile to challenging patients like Pooh because they think their work won't make a difference.
He also said physicians need to be aware of the social determinants of health.
"It's a moral injury," Damania said of burnout. "We know what Mr. Pooh needs is our attention, compassion and for us to look at his entire situation. We have to ask, 'What hole in your life is that honey filling, Mr. Pooh, that you are willing to eat it even though it's killing you?'"
Damania said that when he worked in a hospital, he often discussed with his colleagues how many of their patients would have needed to be hospitalized if they had had a relationship with a family physician.
"The answer was never more than half," he said. "It's preventable. That's not just an economic tragedy, it's a human tragedy."
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