Bridging business principles with emergency medicine [PODCAST]

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“We created a core team of individuals from different levels and functions who met daily. This team’s purpose was to receive and synthesize department-wide information and transform it into new ways of working for our doctors, nurses, ancillary, and support staff. We had a compelling vision which was shared with our department. We made it clear to everyone that they were supported and valued and that we would do everything we could to save as many lives as possible. We knew the importance of making sure that our staff felt heard, and we communicated our change while building upon the positive in our department. We used the facts in combination with the sentiment and feedback received from our co-workers prior to making decisions.”

Josh Schwarzbaum is an emergency physician.

He shares his story and discusses his KevinMD article, “How COVID accelerates change: Bridging business principles with emergency medicine.”

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Today on the show we have Joshua Schwarzbaum. He’s an emergency physician, and he wrote the KevinMD article “How COVID accelerates change: Bridging business principles with emergency medicine.” Joshua, welcome to the show.

Josh Schwarzbaum: Thank you. Thanks for having me.

Kevin Pho: We’ll get into the article in a little bit, but first off, can you share your story and journey to where you are today?

Josh Schwarzbaum: Throughout growing up, I always thought about being in business or medicine. I wasn’t really sure which one, and, to make a long story short, I guess I ended up kind of doing both a little bit. My journey took me through college and medical school, and I decided during college that medical school was the right choice for me. However, I always maintained kind of an interest in business and principles of business, and so much about business affects our environment and our hospital systems, and just our communities and our world and everything. So I ended up going to medical school. That’s kind of what felt right to me at the time, and it still does, which is good.

So I went to medical school. I was thinking about going into psychiatry or emergency medicine, both of which I think have a lot of similarities and obviously a lot of differences as well, but I decided on emergency medicine in the end. After that, which led me down the path of working in the emergency room, basically I did a subspecialty in emergency medicine: emergency medical services (EMS) and disaster medicine. And then I also got board-certified in addiction medicine recently. So in terms of the medical world, I kind of have a couple of different niches that I enjoy working in. And then I’m finishing up my MBA now also, in the next couple of months. So I kind of still had that business stuff going on from when I was younger, and I still took it along with me and decided to pursue my MBA.

And then working in the ER now, and working in addiction clinics, and even with EMS, you really see how business and medicine are so important, how you need to understand the two to be able to work together. And then even now with COVID, as we’ve seen, the business world has really been upended by what’s going on in medicine, and for businesses to have medical people on their teams is quite important, especially in today’s day and age. So many changes have been made, so many decisions have been made because of medical things that have been going on. Having people around who are capable of understanding medical knowledge, and being able to read medical literature and texts and journal articles, and interpret them and clarify them for businesses, and be a part of business teams and help them guide decisions, I think is extremely important.

And additionally, I mean, working in the ER and addiction medicine has really given me kind of an opportunity. I get to meet tons and tons of people. I can meet a couple hundred people a week in the emergency room, brand-new people I’ve never met before, and it’s given me kind of a different perspective of looking at life, ways to look at other people, but really, more importantly, ways to look at myself, and how to take what I’ve learned and what I see and how to work on myself through those lenses, and just constantly strive and create better surroundings for myself, essentially.

Kevin Pho: Now, through your lens as an emergency physician and addiction medicine specialist, give us some specific examples of that intersection between business and what you see in your view of medicine every day.

Josh Schwarzbaum: There’s a lot of focus on throughput. There’s a lot of focus on doing the right test for the right people, not just throwing a kitchen sink at people necessarily. There are costs associated with everything. We don’t necessarily know what those costs are as clinicians working in an emergency room or in a clinic; sometimes we do, depending on what type of practice we’re working in. But there are costs associated with everything, not only financial costs. There’s time cost. If someone comes into the emergency room and I suspect that they have acid reflux or something, you could theoretically order an ultrasound, blood work, a CT scan. There’s a lot of cost associated with that, and then there’s a lot of time that the patient needs to spend in the emergency room waiting for all these tests to show up, waiting for the results. There are radiologists who have to go read the tests. There are a lot of downstream effects that happen with one decision. One decision that I make in the ER can have an impact that goes on for an entire course of the year, potentially, or even an entire hospital stay.

There are, unfortunately, a lot of biases that happen, and one of them is called anchoring bias, where we anchor on a certain diagnosis, and this often starts in the emergency room. If I anchor on a diagnosis, right or wrong, let’s say, and admit the patient to the hospital, that anchor may stay with that person for quite some time. And if it’s the wrong diagnosis, that’s potentially bad for the person. It can lead to a whole bunch of diagnostic tests that aren’t necessary, financial costs, time, all that sort of stuff. And I think having an understanding of, and getting a better understanding of, what’s going on, if we’re able to get a better idea of all these other things that are going on around the patient that we’re seeing, and not just the small kind of view, I think we’re able to treat a patient in his or her entirety a little bit better.

And it’s not so simple. It goes with a lot of communication. You really have to be able to speak to your patient. Emergency medicine is sometimes difficult in terms of the amount of time that we have with each person, because there are people coming in through the door no matter what, and continuing on or not, the doors never close. So it’s important to have that communication, to be able to develop that relationship very quickly. And a lot of business is also about relationships, about communication, about synergy. How can I as a physician create that synergy, have that high level of communication, really be able to understand someone within a minute or two minutes of meeting them, and ask them to tell me very personal things, to be open and honest from my end and from their end? So these are the ways that I kind of see that business and medicine really intersect.

And in the business world, having gone through a lot of the MBA classes, leadership classes, communication skills, development skills, that sort of stuff, these are things that I really believe should be taught to physicians in medical school, and even in pre-medical school. Should we talk to people in college and in high school? I mean, this is the foundation of who we are. Humans in general, we’re social people. We need to be able to interact, and we often don’t learn these things.

And within addiction medicine, I see this as well, very, very much. A lot of the reasons why people get into addiction are because of a lack, a lot of times, of communication from childhood, in various different ways, a lot of instability, a lot of trauma. And it’s what we say to ourselves and how we deal with these situations that can then have an effect on us years and years later. When we’re younger and dealing with addiction, or a little younger and playing around and doing whatever we’re doing, we don’t necessarily even understand the effects that it’s going to have on us later on in life until it’s too late. And then all of a sudden you’re 10, 20, 30 years into an addiction, and all of a sudden it’s like, “How do I get myself out of this?”

And I think having these skills, and teaching these skills, and speaking about these skills of communication, empathy, can really help change the face of the way that we practice medicine, and even the way that we have relationships in our everyday lives, with our husbands, with our wives, with our children, with partners, with patients, with business associates. I mean, this is foundational to human life.

Kevin Pho: So let’s transition now into your KevinMD article. It is titled “How COVID accelerates change: Bridging business principles with emergency medicine.” Now, for those who didn’t get a chance to read that article, can you just walk my audience through it and share the story of why you decided to write it?

Josh Schwarzbaum: Yeah. I decided to write it because everyone had to go through change, through a lot of change, with COVID, and the change had to happen very quickly. It was something I’m kind of used to in emergency medicine, because we have to change a lot. We’re evaluating a patient who comes in, and we don’t know a lot about what’s going on with them, and something may pop up, and we may need to change the direction and be open to that. And often change takes a lot of time. It’s something that we don’t like as people, generally. We get insecure and uncertain when we have to change. We like things the way they are; we like our comforts. And COVID really upended that, and we all had to change.

And we saw that when we started seeing the reports of what was going on in China and started to prepare for COVID. We didn’t even really think that it was going to hit us as bad as it did. We’ve dealt with other, we haven’t really dealt with them, but we’ve heard of other highly communicable diseases, Ebola, SARS, that sort of stuff, that we’ve always prepared for, but it never really quite hit us the way that COVID hit us. And all of a sudden we were in the midst of an onslaught of patients coming in, very, very sick patients in our hospitals, and we could not operate the same way that we were always operating. We needed to change. We had absolutely no choice.

And there are models of change, and looking at the models of change, I think, did help us. The one that I outlined in the article was John Kotter’s. He writes about “Accelerate,” his eight-step model of change, and we kind of used that, and the way I laid it out in the article is how we used his model to really help influence a change in our department. Now, we did have an advantage, that COVID was upon us, so that helps generate change, because there’s no other choice. You have to do it; otherwise you really sink or swim at that point. So that really kind of helped accelerate the change a little bit more as well.

But I do think that we’re always looking, in our lives, for continuous improvement. In our jobs, we’re always looking to improve something. We always want to better our value proposition. We want to get new customers. We want to reach out to new people, bring in new people to hire. We’re constantly changing. If we stay still, the world is changing around us, and we’re just going to end up somewhere where we don’t want to be if we’re not changing with our surroundings.

So I think having an understanding of how to change, and really a lot of us, I think, were able to get, or hopefully we’re able to get, an understanding of how to change through COVID, because we didn’t have a choice. We had to do it. And now that we have some time, that things have calmed down, to take a look at what we’ve done over the past year, and the changes we’ve made and how we’ve made them, and see how we can implement these principles into our lives for the future, and take what we’ve just gone through and really make it into something to guide us as to where we want to go, and not just let our surroundings take us.

Kevin Pho: Now, what were some examples of specific changes that you did make in the emergency department, and what were some of the challenges that you faced in implementing those changes?

Josh Schwarzbaum: Yeah, I think one of the biggest changes we made was having daily briefings in the emergency room. The challenge to that was that we had to be there. Someone had to be there very early in the morning. We wanted to catch both shifts, both the night shift and the day shift, so people had to be there from probably about 5:30 in the morning who may not have typically been there. So we would have a meeting with the night staff and with the day staff, and that, I think, is probably one of the biggest, most important changes that we made. We got instant feedback about any major issues that were going on, and even not major issues, but issues that we thought were going to impair or hamper our care, basically.

And it was not only to get issues but also to give critical updates. That was going on back about a year ago, March, April time, in New York, when we were really dealing with a lot of patients. We needed to give people updates as to what was going on, what the changes were that the department was making as well. And also we wanted to get their immediate feedback, so if we weren’t seeing something right away on an administrative level, we would be able to find out about it right away and course correct immediately.

And that was challenging, because we had to work quickly. We had to organize with other departments in the hospital, environmental services, registration. We had the ICU, we had surgery, all the other departments we had to work with very, very closely, and we were working with people in a way that we’d never worked before, and we had to do this all very, very quickly. And that was a challenge. But I really think that having the administrative boots on the ground, really hearing the people who were working in the ER at the time, getting the feedback, and making immediate changes to those, was probably the most important thing we did. And even today, when I talked to people about our COVID response and what they felt was the most important thing, that’s what they say: really having people come down every day to hear about what was going on with us. That was really kind of what helped us get through it the best.

Kevin Pho: A lot of times when there are changes to the clinical flow, or just changes to the department itself, there’s a certain amount of tension between the clinicians and the administration. What was the case during this particular scenario? Were you guys still siloed between the clinicians and administrators, or did everyone pretty much have that same goal and work as one?

Josh Schwarzbaum: Yeah, we generally worked as one. I mean, the nice thing about our department is all of our administrators within our department of emergency medicine are working clinically in the emergency room as well, so we do have an idea, in general, as to what’s going on. But that being said, whenever there are changes that are made, there’s obviously resistance to change, as you had mentioned.

But with this, I think having us down there every single day really helped with that, because if a process that we tried to put in today wasn’t working, tomorrow we would get rid of it immediately. We didn’t have the time to sit around and look at metrics and see, “Is this working? Is it not working? Let’s go measure this for two weeks, three weeks, a month.” We didn’t have that time. So that’s why us coming down there every single day, I think, was important, and it was felt by the staff, and it was appreciated by the staff, and it really helped minimize the resistance to change, because they knew that we were taking their feedback seriously and we were pivoting based on the feedback that we were getting every single day.

Kevin Pho: Now, do you envision any of these changes persisting as the pandemic winds down?

Josh Schwarzbaum: Yeah, I mean, we do have some of these changes that have persisted, and I think it’s also a good springboard for ways to organize future change, and to look at what worked and what didn’t work. And it’s a good way to kind of understand people. I mean, we can see that when people are under pressure, a lot of things can happen. A lot of red tape gets broken down; a lot of the bureaucracy gets broken down. So how do we take those times? We don’t necessarily want to be in those times again, where we were in March of last year and April of last year, but we want to take some of those principles from that time and be able to incorporate them into our everyday practice.

So how can we work best as teams? That’s something that we needed to do. We had clinicians coming that we hadn’t necessarily worked with as much in the ER. We had people from all over the hospital coming down. We had different units opening up. We had, like I spoke about, the daily briefings. So we’ve taken pieces of this stuff that we’ve done and tried to implement them in different ways, to hopefully keep the change going and to keep the communication lines open.

And, I mean, what we really learn, communication is something that we talk about all the time in disaster medicine and EMS, and really having open lines of communication is essential. That’s probably one of the top things that you’ll hear from people after going through a mass casualty incident or something: One of the most difficult things is communication, face-to-face communication with the patients, or even via two-way radios, that sort of stuff. It’s difficult, and figuring it out is constantly a process.

And what we did then worked. It had to work. And we try to take those principles, what did work, and we’ve implemented it now to have these types of meetings, the administration coming down. It’s not as frequent as it was during the pandemic, when it needed to be that frequent, but getting people heard, making sure that people feel like the administration knows what’s going on with them, and not only knows what’s going on but is responding to their issues on an active basis, is something that’s critical. We’ve really taken that to heart.

Kevin Pho: We’re talking to Joshua Schwarzbaum. He’s an emergency physician, and he wrote the KevinMD article “How COVID accelerates change: Bridging business principles with emergency medicine.” Joshua, you mentioned earlier in this interview that pretty much everybody in health care really needs some business and leadership classes or skills, but not everyone can go out and get an MBA, for instance. So what would you recommend are some resources or books that physicians and even medical students can read to really get that business acumen that can help them further on?

Josh Schwarzbaum: I think there are a couple of books that would be good for everyone to read. Stephen Covey’s book “The 7 Habits of Highly Effective People,” I think, is a great foundation of a book to read. I think it’s good about figuring out about yourself and also about how to communicate with other people, and that’s, I think, a very good foundational book. After that, I mean, I think it depends on what people’s interests are. There are so many different self-help kind of books and different ways about communication to read out there, and a lot of them tend to be kind of similar. So I would advise people to kind of look at what their interests are, find an author who speaks to their interest, and don’t worry too much about it, because you’ll probably get what you need to get from the book that you find. I think that is a good place to kind of start.

And then after that, I mean, depending on what you’re looking for, “Thinking Fast, Thinking Slow” was also a great book. Daniel Kahneman wrote that. Yeah, that was a great book too, which talks a lot about different biases that we encounter, the way that we think, and it kind of breaks down our different, he calls it System 1, System 2 processing, of the way that our minds kind of work: if we think quickly and more from our gut, versus more deliberate, thought-out thinking from our mind. That’s also, I think, a very important book to read for clinicians. It really helps us understand. We hear a lot about bias in the media nowadays especially, but there are a lot of different types of biases out there, and it’s not just what we think about when we hear bias. The way we think, the way that we make decisions, are often influenced by our biases.

Another book, actually, now that I think about it, which I thought was a pretty cool book, is called “Self-Talk,” by Shad Helmeter. It was interesting. His premise is that a lot of the way we respond is how we talk to ourselves, and if we change the way that we talk to ourselves, then we change the way we respond to situations. And I think language in general is another key piece that we don’t hear enough about or talk enough about throughout our education. The words that we use, the things that we say, have a huge impact on our patients and on the people around us, but also on ourselves. The words that we use, that’s what creates our reality, the way that we think. And by changing the way we think, by changing the way we talk, we’re really able to change our reality.

I see this every single day in the emergency room. I work in the South Bronx. We have a lot of patients there who are dealing with a lot of different psychiatric issues, and a lot of violence. And when people come in, we could say one thing that can really trigger them and take them somewhere they didn’t necessarily come in that way, solely because of a word we said, a sentence we said, the way we said it, our tone of voice, that sort of stuff. You take that same patient with a different clinician who maybe has a little bit of a better way of speaking, and that patient, who could be very, very agitated, can get calmed down, and it’s just because of the way that we talk to people. And I think that looking at these things, and researching these things, and reading about these things, and practicing these things can really help us as clinicians and as people.

And we talk a lot about burnout and stress, and a lot of this stuff is real. There are things within our sphere that we can influence, and by looking at these things, we have the ability to make these changes for ourselves every single day. And this is one of the beautiful things about medicine: Every day we have the ability to interact with people. Most physicians do see multiple patients throughout a day, and just because one bad interaction happened doesn’t mean we can’t change it for the next one. We have this opportunity to constantly look at what happened and do something differently the next time, and we get that real-time feedback, which is something that’s extremely important too.

If you really want to be able to generate change, you need to know what just happened. If someone tells me, “This is what you did two months ago; you need to make a change,” it’s already lost. Two months ago, I don’t remember what I did anymore at that point. But when you have this real-time feedback, it’s something that we’re able to do, and we’re really able to implement it. But it’s the work, it’s work we need to do. And to me it’s just as important as studying for the boards, doing something like this, because it really makes our lives better and makes our relationships better.

Kevin Pho: And my final question: What’s your take-home message that you want to leave with the KevinMD audience?

Josh Schwarzbaum: My take-home message is: Try and find your values. If you’re able to find what you value in life and set up your goals based on your values, you will be able to lead a productive life, a happy life, a meaningful life. And by knowing your values and what you stand for, you’re also going to be able to start seeing those things within people. When you see those values within other people, the perspective that you have about other people will change, and you’re going to start seeing a lot more good, a lot more of those values within other people. Your interactions with those people are going to start to become a lot better.

And you’ll see, as you strengthen this more and more, the negative sides of practicing medicine, the negative interactions we have, they fall off and they go away. And by strengthening these positives and really finding these things and focusing on them, they grow. And it takes time. You may not see it right away, but it does happen, and it will be there if you practice. Like anything we do, the more we talk about something, the more we focus on something, it springs up and it grows. That’s what happens in life, and it’s amazing to see.

Kevin Pho: Joshua, thank you so much for sharing your time and insight, and thanks again for being on the show.

Josh Schwarzbaum: Thank you so much.

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