Doctors and patients are not the enemy here [PODCAST]

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He was sued for a case he barely remembered, and five years later it pushed him out of medicine. It is not just malpractice. Jordan Grumet is an internal medicine physician and the author of The Healthcare Heist: How Physicians and Patients Can Unite to Transform Health Care. In this conversation he traces how third parties like insurers, pharmaceutical companies, private equity, and malpractice lawyers pull money and agency out of the system and leave doctors and patients worse off. You will hear why most malpractice suits are dropped before court yet still drive billions in defensive medicine, how business entities that never took the Hippocratic Oath end up deciding how medicine is practiced, and why doctors and patients are pushed into feeling like opponents when they are actually the only two real stakeholders. Grumet makes the case that shared storytelling can close the gap between them. You will hear how doctors and patients can start taking power back, and the specific steps Grumet says both can take today.

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast. Today, we welcome back my friend Jordan Grumet, internal medicine physician, and we’re here to talk about his new book, The Healthcare Heist: How Physicians and Patients Can Unite to Transform Health Care. There’s an excerpt from that book on KevinMD, “Why doctors leave medicine after a malpractice suit.” Jordan, welcome back to the show.

Jordan Grumet: Thank you so much for having me. I’m excited for the conversation.

Kevin Pho: All right, so congratulations again on the new book and the continuing success of your podcast. You shared this excerpt on KevinMD from your book, “Why doctors leave medicine after a malpractice suit.” So why did you decide to share this particular excerpt from your book?

Jordan Grumet: Well, most people don’t realize this. I often talk about leaving medicine from a financial perspective. I realized that medicine wasn’t meeting my sense of purpose and identity, and eventually transitioned to talking about personal finance and writing about all sorts of other things. But I rarely talk about some of the stressors of being a doctor.

So I always say things like, “Well, maybe being a doctor wasn’t the thing for me,” but what I don’t say is that being a doctor was also very stressful. There were some things I loved about it, but that stress made me want to leave. And one of those stressors was the risk of malpractice.

I remember when I was a resident, I had a good friend who was an OB/GYN resident, and she was sued. And I remember her saying to me very clearly, “If I don’t win this.” She was not even really related to the case. She was just brought in because she was one of the doctors on the chart. She said, “If we don’t win this case, I’m leaving medicine.” And I remember that stuck with me.

Fast-forward 15 years later, I’m sitting home with my kids watching TV, 8:00 p.m. at night, and we get a ring of the doorbell. I go answer it, and it’s a process server serving me for a case I also was tangentially related to. And long story short, after five years of going through the hell of being part of a malpractice suit, the lawyer pretty much admitted that he never thought I did anything wrong. He was just using me as leverage against the nursing home.

And so they eventually dropped me, but it couldn’t be undone, right? There was the stress that I felt, not only for me, but also the damage it causes to our medical system. Imagine how much we as physicians end up ordering extra tests and sending people for extra consultations, this whole thing about defensive medicine, just because we’re burned from the last malpractice suit.

People don’t realize most malpractice suits are thrown out. Two-thirds of malpractice suits are thrown out before they even make it to court. And then once you get to court, 8 out of 10 actually find for the physician and not for the plaintiff.

Kevin Pho: Now, tell us a little bit about those five years and the stress that it caused you both professionally and personally during that uncertainty as you were sued.

Jordan Grumet: I mean, it was horrible. Now, I had acted as a professional witness in malpractice cases, so I understood exactly what the process was. So I wasn’t naive to this, but it’s just being unsure for all those years, questioning yourself, questioning everything you do.

And here was the problem. I knew pretty quickly once I looked at the case, because I didn’t even remember the case. Remember, most of these cases happen years after you saw the patient. It was a patient I had a glancing experience with, and they ended up dying of a disease that no one was going to save them from. It was one of those inevitable things. And so I knew from the beginning that I probably didn’t really do anything wrong, but that almost caused more anxiety.

Because then every time I went to see a new patient, it was like, “What is someone going to try to blame me for that is only tangentially related to what I’m doing, or something that I can’t even affect? But how am I going to get in front of that?” Right? “How am I going to order the test or send it to the specialist or not even take on that patient?”

And you start realizing how damaging it actually is to our medical system when instead of being objective and using our best clinical knowledge, all these other thoughts are coming in about covering ourselves. And it’s not just covering ourselves, it’s more like I don’t want to put myself in such a stressful, horrible situation again. Most doctors are willing to do whatever it takes not to be there again, and that’s where we end up having these problems.

Kevin Pho: What’s an example of something that you’ve changed professionally, or how you approach patients, after going through that malpractice experience?

Jordan Grumet: Well, let’s look at the big thing. I pretty much decided, just as my colleague had, that I had had enough. And so I like to talk about this idea of sentinel events. I was already disillusioned with medicine. I was already disillusioned with some of the compliance issues. I was already feeling like maybe this wasn’t the thing I wanted to do with the rest of my life, and this became a sentinel event. You’ve now been sued, and that was enough for me to say, “OK, this is the thing that’s going to eventually make me leave medicine.”

And when you start thinking about that, it’s kind of sad, and I always say this about myself. I’m not actually that good at many things. I was actually very good at being a doctor, so it was one of the things I was best at doing. So I was walking away from something I was very good at.

But not only that, there were all these patients who I eventually left, people who I had been taking care of for years. I mean, it was really sad when I left one of my practices as I had started making this decision. I had two elderly patients who I had been through thick and thin with, and both of them died within a month or two of me leaving the practice, and both of them died from things where I look back and say, “Wow, someone who knew that patient might have made some different decisions.” And yes, they were elderly, and yes, they had medical problems.

I had staff who basically lost their job right after I left mine. I mean, you start looking at this and realizing that when, for instance, a lawyer decides to sue a doctor for leverage against a nursing home, they feel, and I do believe this, they feel like they’re standing up for patient rights and trying to protect the person who’s come to them for help.

But there are all sorts of butterfly effects of this. There are all sorts of other people who are actually affected, and I don’t think we talk enough about the profound effects of everything that happens in medicine. So malpractice is just one example. We don’t talk about the butterfly effect of insurance companies and pre-authorizations and denials. We don’t talk about pharmaceutical companies extending their patents so that people can’t afford their medicines. All of these things, all of these parties that are inserting themselves into our medical practice, have a real effect on patient care, on the economics of the system, on the well-being of the doctors. It’s all connected.

Kevin Pho: Aren’t there statistics that show that the majority of physicians will be sued at least once in their lifetime? And for those physicians who stay in medicine after these sentinel events, as you put it, tell us the effect it has on these physicians, not just professionally, which we talked about, but also their interpersonal relationships with their families, with their children, with their spouses.

Jordan Grumet: Yeah, so the data, and I don’t have the data right off the tip of my tongue, but by the age of 55, something like 50 to 60 percent of doctors are sued. And by the time you get to the end of a career, it’s even more. And you have to remember, lots of doctors are actually in very low-risk specialties. So if you’re a pathologist, you’re probably not going to get sued. There are all sorts of fields that don’t get sued as much. So if you’re an emergency room doctor, if you’re a neurosurgeon, if you’re pretty much any kind of surgeon, your risk of being sued is huge.

And so then you start thinking about, well, how does it affect us? Well, we already talked about this idea of defensive medicine, and we’re talking billions and billions of dollars a year. The best study I could find was from the early 2000s, and they found that it was something like $55 billion a year on defensive medicine compared to something like $40 billion that was actually given out for malpractice cases. So we’re talking about huge numbers here.

But then there’s also the medical malpractice stress syndrome. And so basically, physicians suffer a version of PTSD. It affects the way they practice. It affects their disillusionment with their patients, right? When doctors and patients are already made to feel like combatants, there are all sorts of things that get in the way of the doctor-patient relationship, everything from electronic medical records, which is a physical barrier between doctor and patient, to those things we talked about, like the pre-authorizations and the denials. All sorts of things, and medical malpractice, are keeping doctors away from patients already.

But now you have a doctor who suffered a version of PTSD from being sued, and it’s affecting their interpersonal relationships, their relationships with colleagues, their relationships with their families, and yes, their relationships with their patients. None of it is good. We’re starting to realize physicians already come out of medical school with PTSD, right? We know this. People go into medical school excited, ready to become physicians. More than 50 percent of them come out depressed. And so this is a real problem. The medical experience is hard enough as it is. To also have PTSD related to being sued just makes everything worse, and it’s just not good for the mental health, and that’s why we see physicians opting out.

We see more physicians than ever leaving clinical medicine to take on corporate jobs. We see people like me retiring early and pursuing financial independence. We see people moving more to social media. Right now we have these longevity influencers, and all these people who’ve decided that they’re going to really spend a lot less time taking care of patients and a lot more time out there talking about things on social media. And so the effects are just profound.

Kevin Pho: Now, this particular story came from your book, The Healthcare Heist: How Physicians and Patients Can Unite to Transform Health Care. Now, what were some of the reasons why you decided to write this particular book?

Jordan Grumet: Health care is broken, and we know this. Basically, we have these third parties, whether that’s insurance companies, pharmaceutical companies, private equity, venture capital, electronic medical records companies, or medical malpractice lawyers. We have these third parties who are sticking their hands in the cookie jar, taking all the money out, and leaving doctors and patients alike bereft. And they’re so entrenched and there’s so much lobbying that we know nothing’s going to change, right? Congress is basically barricaded up. They’re never going to change anything. Even Obamacare, which promised the beginnings of some change, in order to get it passed, they had to pretty much give up on a lot of the things that were actually beneficial.

We are never going to be able to change our health care system unless we literally have a revolution. Now, I’m not talking about bayonets and guns and those kinds of things, but in American history, as well as in world history, you have lots of peaceful revolutions when the main stakeholders come together and push as allies for change.

And who are the stakeholders in our medical system? They’re the doctors, nurses, all those people who give care, and then there’s the rest of us, all the patients. Everyone else is kind of a third party who is, again, taking money out of the system but isn’t really helping anything.

So the problem is right now doctors and patients actually feel like they’re always fighting, right? Because of medical malpractice, because of electronic medical records. There are some other reasons why doctors and patients feel like they’re fighting. Things like managed care and the gatekeeper model, which makes doctors the ones responsible for withholding care from patients. So that keeps us from becoming allies and stakeholders together.

And so the only way we’re going to get real change is if we come together and push for change, and I talk about in the book, the way to do that is actually through shared storytelling. Whenever we’ve had major peaceful revolution in the United States, or again, outside in the world, it usually revolves around a big story.

I like to talk about Civil Rights, for instance, in 1965 and Rosa Parks. The story of Rosa Parks and not being able to get a seat on the bus was the story that brought all the stakeholders together to fight off the entrenched interests in Washington.

We’re getting closer. I think Obamacare was a step in the right direction. I think you see it in our political systems nowadays. You see a lot of people, young people voting, for instance, Democratic Socialist. You may or may not believe in what they’re talking about, but there’s this real push, especially in the young people, to start pushing things like universal health care. So I think we’re on the cusp, but in order to do that, doctors and patients must feel like allies. The intimacy gap must be closed, because right now most patients don’t feel really connected to their doctors at all.

Kevin Pho: Yeah, and is that really the doctor’s fault? Or is it the system itself that makes doctors see patients in 10 to 15 minutes in a primary care setting?

Jordan Grumet: I think these third parties have exacerbated a system that was there already. If we look at health care, you go back to the early 1900s. First of all, your doctor lived in your neighborhood. They went to your church, their kids went to your kids’ schools. They came to see you at the house if you had a problem, if you couldn’t make it over to their office. And a lot of times if you couldn’t pay, you would give them some eggs, or there would be some type of bartering. So back in the day, there was natural intimacy because your caregivers lived in your community and you ran into each other all the time.

Fast-forward to today, most people drive 10 to 15 miles to get to their doctor’s office. Their doctor doesn’t live in their community. They don’t run into them on the street. They don’t know their families. They don’t know their children. And so doctors are doing what doctors always did, which is they’re creating objectivity and distance in the exam room. They did that 100 years ago too, but you already knew them and already had the intimacy of normal life, so it wasn’t as big of a deal.

But nowadays, we barely know our doctors. We feel like we’re changing doctors all the time. Our doctor in the office doesn’t see us in the hospital anymore, and so there’s no intimacy of community that used to be there, and that’s why it’s gotten really exacerbated. But, and I will say this, as doctors, the onus on us is that we’ve always done a really good job of telling people what we know. So we’re really great at getting on social media or giving talks about hypercholesterolemia or coronary artery disease or dealing with strokes. We’re really good at telling people what we know. We rarely tell them who we are.

That is starting to change. I like to point to the TV show, which I never watch because it would give me PTSD myself, but the TV show The Pitt is actually a perfect example of how doctors can be out there telling their stories. Now, The Pitt wasn’t put together by doctors, but there are a lot of doctors consulting, and Noah Wyle has been very deeply involved in the medical world since he did ER all those years ago. So we’re starting to see more and more of this, but it’s a version of shared storytelling outside of the exam room, but in society, that lets people know that we might not live in your community anymore, we might not even visit you at your house anymore, but we’re deeply intentional people who want the best for you and got into this profession because we truly care.

Kevin Pho: And of course, during my social media journey, you’ve seen as well, I think that social media certainly gives doctors the tools to share a little about their story and be a little more transparent. And sometimes, as you know, that goes against the traditional training of a physician who is supposed to be dispassionate in the exam room, be objective, as you say. Now, what are other ways physicians can tell patients more about who they are? A lot of their autonomy, as you said, is lost because there are so many entrenched third parties in that cookie jar that prevent doctors from bonding and sharing that time to have that shared storytelling with patients. What are some other ways they can do that and we can turn the tide?

Jordan Grumet: Yeah, I certainly think social media’s incredibly powerful. And so if you’re already out there posting about your field of study, let’s say you’re maternal-fetal medicine, and so you’re out there posting articles you’ve written and things that you talk about with your patients, and maybe you’ve done some instructive videos. We also have to tell them what it feels like to be a doctor, and again, you don’t want to do that in the exam room. That’s the wrong place. Your patient comes to you for a problem. You don’t want to focus on you.

But out in the world we also have to say, “Hey, boy, this is what a bad day looks like,” or, “Hey, I was 30 minutes late to your appointment and I felt that you were really angry. Let me tell you a little bit of what was happening at the moment.” Again, fictional stories, personal information changed. We can’t share information that’s specific about patients, but we can give people a little bit of the background to understand.

I used to write, as you know, a medical blog for years called In My Humble Opinion, and I was practicing, and eventually my patients started finding my blog posts. And it was funny because they would come into the office and they’d say, “Oh, I saw your last blog post.” And they almost always say, “Boy, I had no idea my doctor was dealing with all those things at once.” And just that little piece of understanding is amazingly helpful.

So we can get out there. We can use our voices. We can get involved in medical advocacy. I mean, there are all sorts of societies of humane medicine, all sorts of things in which we can get involved and let people know not just what we know but who we are.

Kevin Pho: Now, tell us the danger of physicians not doing that. Let’s say we continue with the status quo, and private equity and other third parties continue to encroach on our autonomy. What’s the danger of not acting?

Jordan Grumet: Well, I think we’ve already given up a lot of agency, right? So if you go, I think, what was it, 2017, 2018, we flipped from being more physician-owned practices to more private equity, venture capital, and academic practices. When we give up our agency, what we’re doing is, believe it or not, we’re actually going against the Hippocratic Oath.

Because when you go work for private equity or venture capital, and the people running the business decide that you need to see patients every 10 minutes instead of every 15 minutes, or that we’re not going to order this test anymore because it’s too expensive, or you’re going to start pushing this test because it’s one that we offer, basically you have these other entities practicing medicine, not physicians, but business entities that start to practice medicine.

The problem with that is business entities don’t take the Hippocratic Oath. They don’t even apply any standard of care like we have to because of medical malpractice. But what they do have is a fiduciary responsibility, so businesses are bound to pay their shareholders back and watch after their shareholders’ financial needs, and we’re allowing that to decide how we practice medicine.

And so we as physicians become even more pawns in a game that we don’t control. But here’s the thing. We really only have two main stakeholders: those who have the knowledge who can then give it to help society, and then the society that needs it. That’s it. Everything else is a little bit superfluous. And only when we realize that and start acting like it are we going to see the tide shift.

Kevin Pho: We’re talking to Jordan Grumet, internal medicine physician and author of the new book, The Healthcare Heist: How Physicians and Patients Can Unite to Transform Health Care. Jordan, let’s end with some of the main messages you want readers to come away with after reading your book, and then end off with some take-home messages.

Jordan Grumet: Basically what I want people to get from this book is that you can change things. All is not lost. Just because our medical system seems unfair and uneconomical now doesn’t mean it has to be that way. And so in the future, I think with a little bit better storytelling and a little bit of those stakeholders coming together, everything will change.

But in the meantime, I want to talk to you, because a lot of doctors listen to this. So I want to talk to you as a patient instead of a doctor. If you want things to change today, there are some things you totally can do to take money out of these third parties’ hands. So if you’re going to see a doctor yourself, and you can, find a doctor in private practice. If you’re getting your blood pressure pills refilled or getting a new blood pressure pill, get a generic. If you are having a test go through pre-authorization or be denied, appeal it. All these are little things we can do to tell these third parties as patients that that’s not OK.

Kevin Pho: Jordan, thank you so much for sharing your perspective and insight. Thanks again for coming back on the show.

Jordan Grumet: Thank you for having me.

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