From the Front Lines of Medicine: A Prescription for Better CarePodcast
Guest: Dr. Robert Hauger
Welcome to 360 degrees of healthcare with Dr. Stan an in depth. Look at our industry from our very own chief medical officer who will talk with other medical and industry professionals on the changing and evolving landscape of the healthcare system from the inside, and now live from zero studios, our very own infectious disease expert, Dr. Stan Schwartz,
Welcome to 360 degrees of healthcare. My name is Dr. Stan Schwartz. I’m an internal medicine and infectious disease physician. Who’s had lifetime roles as a medical student resident post-grad fellow researcher, practitioner, hospital, epidemiologist, medical director of a small and later and large multi-specialty clinic. And most recently co-founder of a digital health enterprise. And unfortunately, as I get older, my role as a patient, these things have all given me a 360 degree view of medicine that I really hope to, to share with you all my guest today is Robert Hauger MD. He’s a board certified primary care internist fellow of the American college of physicians, and also the Oklahoma governor for the American college of physicians. If you’re listening live, please use the Q and a button at the bottom of the screen. And we’ll try to get to your question and I’m gonna let Dr Hauger introduce himself. But first I have to give you a disclosure. I’ve known him for, in several roles over the past couple of decades, as both a colleague and as a trusted advisor. So with that, Robert, tell us about yourself.
Thank you, Stan. It’s really a pleasure to be with you tonight. Um, a as Stan said, we’ve known each other for, for the better part of 26 years, which has encompassed my career here in Tulsa. Um, once I graduated from the univers, well, the university of Oklahoma, and then went out to Seattle to do my internal medicine residency. I decided to come back here to be closer to family and, uh, joined the health system 26 years ago. I’ve had the honor of serving in many roles, uh, in leadership, including a chief of staff of St. Francis, uh, hospital. Uh, and now currently I’m honored to be the governor of the, um, Oklahoma chapter of the American college of physicians. And, uh, very proud of, of, of that, that honor.
So one of the things I’ve been really fortunate about Robert is to watch you over the past decade, work in the field of advanced primary care, basically through a Medicare innovation program. Can you tell me what you learned from that program? And tell me how the program changed you and what do people need to know about advanced primary care?
Well, so the program was interesting in that it had an interesting premise that I still remember, which if you think of the healthcare spending as a hundred percent of the pie, the, the premise was if you invested in the 5% of the spend, that is primary care, you will be able to impact in a positive way. The other 95% of the spending. And interestingly in Oklahoma, that was the case. We were able to do that year on year during that basically eight or nine year program. And that was pretty amazing to me because the only thing that was the only commonality was that we were all a part of that program. What did I learn? That’s a good question. And what I’ll tell, tell you is I, I learned that continuous quality improvement that, um, team based care can actually happen at the primary care level. And you can use data to change, uh, the way you practice medicine in a meaningful fashion.
So you use the term team care, and I hear that a lot about advanced primary care. What exactly does that mean? Because when I hear team care, does it mean I’m not gonna get to see the doctor anymore?
Well, so team care, this is the way that I like to think about it. When you, even before you enter my office, um, you have to interact with people that are part of the team. Uh, it may be a receptionist in my office and from, so really from time zero, you are, you are interacting with my team. Now, when I was a young physician, I thought that, you know, my responsibility was to do the doctor part of the care of the, of the, of the visit. But what I learned, uh, over the years is that my, my responsibility is to the entirety of care. So yes, I, I, I think care of patients is a team based sport. And, you know, a lot of times you, you sit there and you say, well, well, I’m not sure I wanna see a nurse practitioner or, or maybe I, I, I could see a nurse practitioner, but I’m a little nervous about that.
Or can somebody else take care of me? And what I will tell you is for chronic conditions, maybe a nurse practitioner is the perfect person to take care of you. Maybe he, maybe he or she could do better than me, but if you have an undiagnosed symptom, or if you have a, uh, a, a worrisome symptom that you wanna see me for, uh, you should be able to do that. And that’s part of the team based care. It’s you get to see the right person at the right time, uh, for your problem. So it’s not as simple as do I get to see the doctor or not. It’s it’s who do I need to see to get the best care, the quickest, uh, and the most convenient for me
When you talk about the team, was it just resembling the same people you had before, or did the team add any members to be advanced primary care
In, in the primary, in the primary, in the initiative that you spoke of? We added, uh, uh, a registered nurse as a part of the team and had a lot of behind the scenes support, uh, uh, that, that added to the team. And, and again, that, that data collection and simulation and, and feedback was very important, so that when you did make changes, you know, um, all changes hard and only some changes in improvement. And the only way you can know that for sure is to measure what, what improvement happened. So there was a lot of things that were different about, um, the team, but I will tell you is high-functioning teams, whether they include a registered nurse or not, are very important, um, to, to, to the patient and to care in general.
Yeah. Registered nurses used to be decades ago, common in doctor offices, but you know, of late, most primary care offices can afford registered nurses. How did, how were you able to put them in place?
Well, that goes back to that investment that we talk about, which is, uh, you know, again, I think investing in primary care is one of those things that I, I found to be even more important after I participated in that initiative, uh, than, than before. And I thought it was pretty important before, but, uh, you know, the reg registered nurse played a role in, in our office, uh, both as a mentor, as the, the face of continuous quality improvement at the office level. And, and as a matter of fact, you were the medical director. And I still remember, uh, when you came to me and said, we’re gonna, we’re gonna have two nurses in your office, registered nurses. And I go, what am I gonna do with two nurses in my office? And now, frankly, uh, now they have been centralized. And what I will tell you is, um, I can tell the difference and the things that I was able to do with them in place was quite spectacular. And, and again, I think it goes back to that’s one of the investments we need to rethink at the primary care level.
So these were nurses that were not actually seeing patients, you know, in, in a clinical sense, what were they doing?
Well, they would be responsible. So, so I, I, the, the thing about that initiative is they were doing whatever the team needed them to do, but again, it needed to be specific. It needed to be unique to them. And so I was fortunate enough to, so that their day to day activity was chronic care management and making sure that, that the patients got what they needed. Um, and also in the office, they would see patients for, for brief periods of time, that would, and that would kind of particularly like for instance, complex wounds or, or, or if you needed education, they could provide education. But I took it a step far further in our office. And I, I was fortunate enough to have a nurse that had some quality improvement experience. And so I had an executive committee of our office that was responsible for, for quality improvement in the office, at the office level that included those nurse and, um, members of the team, uh, so that we might make those improvements real time and quickly.
How, how big was your office at that time?
Uh, in what respect helped me understand
How many doctors, I mean, that sounds like we,
We had four, we had four doctors, uh, and at that time, and, you know, each doctor had somewhere between a thousand, 1300 patients.
I remember one of the big parts of the program was what they called risk stratification that, you know, virtually every patient in the practice kind of got, you know, categorized. Can you tell our there’s what risk stratification is and, and why it was so important?
Risk stratification is important, particularly when you’re dealing with chronic care management, because you really, depending on what your charge is, you’re gonna have a different population, different risk popul. Let me give you an example. Uh, if you’re really worried about the people who are going to go back into the hospital and have pro or be hospitalized for the first time, you’re gonna wanna focus on the sicker population of patients. And so that was a lot of what the nurse, the registered nurses would, but I think you can broaden that out a little bit, and you can say, well, maybe I want the people who have chronic medical conditions not to get to the point to where they’re gonna be in that, that select group that need, um, care. The only way you can do that is to identify those populations and separate them out. And then you can actually, um, work with them to, toward the goals that, that, whether it’s keeping ’em out of the hospital or keeping the them from becoming one of those people that are at high risk for being hospitalized.
You mentioned goals. One of the things I remember that you really concentrated on was to understand not what patients needed, but what their goals were.
And how important that was to your practice.
Yeah. I think the patient centerness of this activity is very important and you really have to start with the patients where, where they are, and if you don’t have a firm appreciate a, a strong appreciation and respect for what they’re trying to do, it’s gonna be very hard to move the needle, uh, on any of those chronic. And that was one of the skills that I think the team developed as we, as we went through that journey of, uh, of the initiative you spoke of
What happened to, to patient satisfaction, you know, what they call service quality during this whole program. I mean, did, did patients appreciate the changes?
I think undoubtedly they did. Uh, you know, I, I know that they developed relationships with those nurse team members, much like they developed relationships with, with my, um, assistant now. Um, but, and so there was a, there was a, there was a very intimate bond there that really helped in the care of those patients. And, and they had an UN it was funny because the nurses would gain an understanding of how best to approach a particular patient. And it wasn’t one size fits all. It was very, very individualized at the patient level. And that was really, really great to watch.
Did the patients feel like they had somebody on the inside that cared about them?
Absolutely. And, you know, I can count many times that where they would call and specifically ask to speak with the nurse again, not intending to speak to me, wanting to speak to the nurse to get advice, uh, because there was that relationship there. And I, I think it was an important and unique, um, almost Renaissance of the care the, that we gave, uh, in, in that era. It was, it was really great to watch.
One of the things I’ve always known about you is that you’ve been both a very high energy and a very enthusiastic person, you know, and we hear now primary care doc suffering burnout, and on we, and, you know, all kinds of dissatisfaction during the course of all this, have you maintained your attitudes and mental energy and has this advanced primary care transition made a difference there,
You know, burnout in physicians is, is epidemic, right? I mean, at any given point, half of us are burnt out. So a doctor who’s practiced 26 years, like me has experienced burnout very much at some point, right? So, and I guess there, isn’t an easy one size at all, answer to that either. I, I think taking care of yourself, making sure that you realize, and, and I guess I’ve come to appreciate the fact that I’m not gonna be able to do this forever. And the fact that I get to interact in a very personal, compassionate way with patients and they, they too have a, a caring for me has really helped, um, as an antidote to that burnout. It’s something that, that I heard a while back called called mutuality. And it’s not just that the, the pay patient is, is, is the center it’s it’s yes, the patient’s there, but there is a mutual caring of the doctor for the patient and the patient for the doctor. And I think if you can keep that focus and keep that mindset, it really does help with the, with the combating burnout
Talking about burnout. Let, let, let, let’s just switch gears for a second to COVID because that, you know, changed everything.
COVID wait. Oh, COVID yeah.
Oh yeah. You’ve heard of that. Good, good, good. What was it like to suddenly change when COVID hit? Because you know, you you’ve always been an in and doctor just suddenly have to change the virtual care video care and have an empty office.
Yeah. That was a big change. And, and I, I remember a couple of things about that and, and I, and there are some real lessons here about care delivery. The, the first thing I remember is when it, when it first happened, I was fortunate enough to be a part of an organization that was very flexible and stood up the virtual space almost instantaneously. And so I was able to go, I was, I had about two or three weeks where I wasn’t seeing very many people at all to pretty much as many patients virtually as I was in the office before the pandemic hit. And it was about 90 10 is what I remember, 90% of them virtual, 10 of them in person fast forward to today, uh, where virtual care is still, uh, still something that we can do. I saw 10 90, uh, you know, 10% virtual, 90% in person.
I think that virtual care is a tool, but it is not the replacement for in-person care. I, I learned that in-person care the touch of a doctor, the sh the, when we used to shake hands, uh, the shake of a hand is, uh, you know, but the touch of a stethoscope, uh, and being face to face with somebody is very important to patients. And part of that, that healing process in almost in almost any respect. And so while you can use the, the virtual tool, I, I don’t think it’s ever gonna replace, uh, in person care. Uh, but I think it, it should be here to stay because I think it does, you know, one of the things you learn is you can take care of about 80% of problems with just a history. And that’s kind of one of those things that we learned when we were back in medical school, that the physical exam is about 20% and the lab values are less than that in making the diagnosis. And I think that bears out in, in, in virtual care. But again, that’s not what the patients want sometimes.
How often did you have the experience when you started a virtual visit that you thought to yourself? I really should be seeing this patient. I mean, was that common or uncommon?
Relatively uncommon, but, but happens, it happens. I mean, cuz you do don’t really know. I mean, there are certain things that you can predict, right? I mean, uh, if you’re having crushing sub sternal, chest pain with shortness of breath and diaphoresis, I don’t think a video visit is probably very good and neither is an in-person visit in my office, frankly, you need to go to the emergency room. But, uh, so there that happens, sometimes you can triage things like that, but other times you’ll get on a video visit and you’ll say, you know what, um, despite the lighting of your window sill, I can’t really see the back of your throat very well. And I think you need to come in for a visit that happened to me just this week. And uh, and then you have to kind of say you, I think we should stop here or take care of the problems we can now and then get an in person, visit down the road. And that’s perfect. Okay. Patients are okay with that. Because again, that’s, you could say that’s an error, but it’s an easily fixable one.
You know, there’s a lot of digital care taking place. Now there’s a lot of virtual care. There are urgent care centers. It seems like, you know, primary care patients have a whole buffet of ways that they can access care. How has that ability of people to go in many different directions? How has that influenced your advanced primary care initiative? Does it make a difference?
So I think as somebody said, uh, the, the great stability is availability. And I think if you are the easiest one to see at, at any given time, then that’s the one who will probably get to get seen, right. If you’re not, then you probably aren’t. And so that’s why I think access to care is so important. So critically important to, to, to taking care of patients, really, I should be the easiest place to get care. And, and if you can get good care, the care you need at a different place, easier than me. Well, that’s kind of on me, right?
Yeah. One of the things I hear a lot is people saying, you know, the only time I can’t see my doctor is when I’m sick and I need to see my doctor,
Uh, let’s change gears for a second. Your, your background is I am proud of ACP. You’re a fellow of the American college of physicians and you’re regional governor tell our listeners exactly what is a college of physicians who are the docs in this college. And how has your experience informed your thinking about healthcare?
Well, so the American college of physicians and you see the backdrop behind me is part of that, uh, is the largest physic, uh, organization. And it’s a college of internal medicine and internal medicine subspecialists. And what, what my role as the governor has done for me personally, is it’s given me a chance to get out of where I use usually practice medicine and really experience medicine from, from a different perspective. It gives me a look at the rural perspective. It gives me a look at the academic perspective and, and broadens my view. It’s really easy when you’ve practiced somewhere for 26 years to be very comfortable in your little area with your group of people. And I think what, what this experiences has shown me is the, the in particular in Oklahoma, the, the internal medicine doctors and the subspecialists are just over the top. Good. And, and the, and the academic, uh, doctors are just the best, the best anywhere. And, you know, as I interact with governors from different states in the, in the meetings, you, you, that’s, the other thing you appreciate is what brilliant doctors we have in, in this, in this place that we live and how fortunate we are to have them. And there’s nothing that will remind you more of that than going through a pandemic
For those in who are listening, that may not know exactly what in two medicine is. I mean, how’s that different, for example, from family medicine or general practice.
So internal medicine, uh, the way I like to think about it is it’s adult medicine and it’s, it’s specialty training in, in, in basically the nonsurgical adult medicine, healing arts. That would be the way that I would describe it. And, and these are highly trained individuals who are used to taking care of extraordinarily complicated and complex patients. Uh, but they can also take care of you if you’re well, right. And, and can, can get you the care you need. Um, uh, if you’re well, too. So it’s, it’s really the full spectrum of adult care.
So right now there are, you know, internal medicine doctors who work in the office, there are internal medicine doctors who work only in the hospital, and then there are, are a, probably a shrinking breed of internal medicine doctors that work both in the office and the hospital comments about that.
Yeah, I’m one of the shrinking breed, or, you know, you can characterize ’em as the dinosaur, after the media has struck, or, you know, the 1965, uh, Mustang that my grand and father used to own. I’m that, I’m that person. Right? So, so I do still practice medicine, both in the office and in the, in the hospital. And I I’ve done that for 26 years. And while it requires a certain amount of that energy you spoke of, and, and it is a little bit of a different lifestyle than many people are, are wanting in this day and age. What I will tell you, I think there are economies with that, that again, serve as the antidote for burnout serve as, uh, you know, improved care. You know, if you look at the statistics, you might stay a day longer in the hospital than if you were under the care of the hospitalist, but I, I really am convinced that you, your risk of going back into the hospital after you leave is lower. Uh, if you have an arrangement like that, the problem is they’re not making 1965 Mustangs anymore. And so it’s gonna to be really hard to get enough to enough people who wanna do that sort of business with me. And we’re finding that now there are, there are currently seven or eight people at St. Francis who do that work.
One thing I remember doctors saying is that the collegiality of being in the hospital was educational, that they got to watch specialists in different fields and kind of keep up to date when, when they attended in the hospital. Any thoughts about that?
Well, I mean, I think collegiality isn’t important, whether it’s an outpatient doctor or an inpatient doctor, and I think the potential for collegiality, I think going back to what we were talking about earlier, uh, with the initiative, one of the things that I think made it work was there would be in-person meetings, pre pandemic, of course, uh, where we would sit down and, and share ideas. And again, I, I think that’s very important, but I don’t think it’s necessarily relegated to just the hospital practice. I think that experience with that, with that initiative showed me that you can do it as an outpatient and that, that crosspollination and those ideas from a cross town that you never get, that you would never get to hear since you practiced in a health system, that’s, self-contained, uh, really helped me, uh, kind of move the needle on improvement.
So the American college of physicians, uh, you had sent me some material, I looked at a while back kind of their prescription for what’s changing or what they think should change in American healthcare. If you, what are your magic wand wishes for American healthcare, not just for your practice or Oklahoma, but you know, from what you and the American college of physicians are dreaming up, what, what do you think needs to change? And what do you you think will actually come true as a change?
I’m pretty optimistic person stand. So, so I’m hopeful that my, the, the, that aand will be waived, maybe not mine, that that will eventually get to where I think the American college of physicians would. And you’re referencing a paper that was published just before the pandemic in, in, in 2020, January of 2020. And it was the vision for healthcare. And I think that’s a good read, and it really, really is very consistent with, with what I personally would, would wish. And this is what I would wish. Um, I want the patient patients to get the care that they need at the time that they need it by the people or person that they need to deliver it at a low cost, with the least burden to them. And those that provide the care. And, and I think that would be what I would want. I think that’s what I think that’s consistent with, what a, what patients would want too.
We have a question here from a real old friend of ours, who was at the very beginning of the transition, Jay, who you probably will remember, and Jay asked us, how did relational continuity the healing relationships change and work even better in the team model?
Oh, great question, Jay. Thank you for that question. You know, I think, I think it’s interesting, but because high functioning teams, so we talk about the relationship, the, the healing between that goes on between the physician and the, and the patient. But I think that, uh, when you think about it, every relationship on the team is a potential to either detract from healing, but both of the team members and the patients or accelerate healing. And so, so that team based care, uh, really, uh, is, is, is integral to that. But again, just adding the adding team members, um, without an appreciate of that, the importance of, of a high functioning team will, will not solve the problem and will not give you better care.
You know, you, as you mentioned, team, that brings up, I remember that there was a concept of the huddle and, you know, before the plays and football, you guys would huddle tell us what a, what a huddle was in medicine.
Well, I mean, a huddle is just like, you would think it’s the, the team getting together and mapping out the day, uh, usually at the beginning of the day. And I’ll tell you if you want, if you wanna see huddles go away, a good way to do that is to have a pandemic, uh, because it’s really hard for, we tried many things, right? And, and including virtual huddles huddles like this on zoom, and really, it, it, it was very difficult to do in the midst of a pandemic pre vaccine in now it’s a little easier, but we’re ha we have a little bit, we, we haven’t re instituted it, but I think there was some value in the general concept of getting the team together and understanding what the days work was gonna be, you know, calling, calling plays, if you will, in the huddle.
Well, I mean, would you like look at your appointment schedule or talk about individual patients or just what rooms you were gonna use or
What, but both, uh, all of those and, and anything else. And sometimes there would be communications that needed to happen at, uh, at a larger level. And this was the easiest way to deliver them.
One final question I have for you is you talked about data early, you’re using data. Give us an example of how primary care doctor uses data. I mean, not data, that’s just about an individual patient, like their lab work and things like that. Yeah. What kinda data you talking about?
Well, for instance, early on in the comprehensive primary care initiative, what we realized looking at the data was that our readmission rate was higher than our peers. And just like with any, you know, you’ve kind of gotta check your ego at the door when that happens and say, gee, that’s interesting. But in addition, when you have a system that can identify those, those deficiencies and care, if you want to think of them that way, and then address them, it’s not near as ego deflating as it might might B because you have a plan to fix it. And in fact, we put in, we got the team together and tried several things and ultimately, uh, got that, uh, that readmission rate to one of the lowest, uh, in the, in the, in the, in the, in class to some of the best in class. So that would be an example, but again, it takes having that structure of the high functioning team and then leveraging that, so that you’re trying to accomplish a common goal. And, and, you know, if you think about it, think about how every member of the team from the receptionist to the nurse, to the CA to the doctor could impact readmission rates. And it doesn’t take a lot of imagination to realize that each one of those could, if they were told, this is what we were trying to do, uh, figure out creative ways of, of helping
You have a question from an internal medicine. Some physician who asked about there was a program about integrating behavioral health, uh, into advanced primary care, tell our listeners why behavioral health is important and, and what integration with primary care means.
Well, you know, I was, we, we do, haven’t touched on this yet. That’s a great question by the way, but I was fortunate enough to be a pilot that, uh, that actually has now become a permanent part. One of the team members that we have as a behavioral specialist and behavioral health in the, in the office, I can tell you from experience, be done, and it cuz it’s being done today in my office. And so, um, that integration, so the way it works is the behavioral health specialist is in the office. And if I have a patient who, for instance, might have problems with attention or problem with depression or problems with anxiety or problems with insomnia, I text my, my behavioral health specialist and she comes and does something called a warm handoff and then they will be plugged. They, they, the patient can then choose to schedule some time with her. And that’s been invaluable. Uh, when you think about, um, reducing medication use for insomnia or kind of an adjunct for depression, that’s just been a game changer, uh, for, to have the behavioral health integrated into the office. So thanks for that question.
So is a behavioral health specialist like a psychiatrist or psychologist or what
Ours is a licensed clinical social worker and, but a licensed clinical social worker that says has had specific training. So she can, she can do those tasks that we, we ask her to do.
So do people continue to access that same person or is it just, you know, one and done type care?
No, there’s a longitudinal relationship and it depends on what you’re seeing her for, right? If you need, if you can’t sleep at night and you need to read of five sessions to help get a program of cognitive behavioral therapy for, for insomnia, well, then that relationship is gonna be put on the shelf pretty quickly. But if you, if you, if you’re you have refractory depression and you know, a family member has died of COVID 19 and your, uh, you have a, you know, opioid use disorder, then that relationship may be much longer, uh, than just three to five sessions. The design initially was short, short, and then hand off practically what has happened is because again, she’s part of the team and patients expect to see her. Uh, that’s, that’s kind of how it’s working now.
I wonder remind our audience, if you’re listening live Q and a for any questions you have, we’ll try to answer them before we wrap up, going back to the behavioral health, what is the difference between having a behavioral health right in the office versus just referring people to behavioral health? I mean, how much better uptake do you get?
Oh, you know, I mean, I mean, some people aren’t interested. I mean, but I think the majority of people who you’re her it’s much more than if I had you go to the, to the Laureate, um, and get the, the Laureate is a psychiatric hospital that’s affiliated with okay. With Saint Francis. But, but if, if, if you go to a psychiatric hospital, you know, I, I mean, I am reminded of one of my best friends who, who, who told me that he had in. And I said, well, you know what you need to do. You need to go get cognitive behavioral therapy. Uh, and they have great cognitive behavioral therapies over at the psychiatric hospital. And he mentioned to me, I’m, I’m not able to sleep. I’m not crazy. And so again, I think that’s, that helps in, in combat the combating the stigma of accessing behavioral health when it’s, when it’s not in a place that de that delivers behavioral health, uh, the stigma’s a little bit it, uh, heavier there.
Great. Anything else you’d like to share with the audience before we wrap up?
No. I mean, I think this has been a really fun thing for me to do, and I appreciate you having, uh, me on your podcast, Dan, and, uh, it’s great to get together with you and talk, uh, even in this setting and I’ve really enjoyed it. So thank you.
Well, we really appreciate your, your coming on the show for the audience. I want to ask you all to take care and stay healthy. If you’ve taken the COVID vaccine, I and the rest of the population. Thank you. And if you’ve not take some time to sit down with your own physician for a critical to conversation, we hope to hear from you, or be able to talk with you next month on our next show. Thanks very much and have a great day.
We hope you’ve enjoyed the time with our very own doctor Stan for 360 degrees of healthcare with Dr. Stan Schwartz, a part of zero studios in subscribe and review our podcast to keep current with the ins and outs of the medical and healthcare industry from the inside out.
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