The Pediatric Lounge, Where Pediatric Physicians Come to Share Their Stories and Success

099 Leadership, Communication, Compassion and Hope How do we get There?

August 19, 2023 Dr. George Rogu, MD, MBA and Dr. Herb Bravo Season 2 Episode 28
The Pediatric Lounge, Where Pediatric Physicians Come to Share Their Stories and Success
099 Leadership, Communication, Compassion and Hope How do we get There?
Show Notes Transcript

Susan J. Kressly, MD, FAAP, is board certified in Pediatrics and Clinical Informatics and is a Fellow of the American Academy of Pediatrics. She received her medical degree from Temple University School of Medicine. She served her residency at St. Christopher's Hospital for Children and stayed an additional year as Chief Pediatric Resident.

Dr. Kressly believes that all children deserve access to a well-coordinated patient-centered medical home neighborhood, and all pediatricians (including medical and surgical specialists) deserve the resources, payment, and support to meet the needs of their patients and families.

Among her proudest accomplishments are the patients she has mentored into pediatricians. There is nothing more satisfying than watching children say, β€œI want to be like that,” and then have the pleasure of helping them turn their dreams into reality to serve.

"If we give pediatricians the right resources and appropriate payment to be able to serve the families, we can do amazing things. That is what's killing us, the lack of appropriate resources. Yes, all the administrative burden and crap is getting in the way, but as pediatricians, you know, you make a difference."

Lack of cockpit communication recalls the 1999 Korean Airlines crash near London.

COMPASSIONOMICS

Dr. Kathleen Wania from Greece Pediatric Medicine and P.E.D.S

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The Pediatric Lounge - A Podcast taking you behind the door of the Physician's Lounge to get a deeper insight into what docs are talking about today, from the clinically profound to the wonderfully routine...and everything in between.

The conversations are not intended as medical advice, and the opinions expressed are solely those of the host and guest.




[00:00:00] Dr. Bravo: Good morning. It's Tuesday morning and I see a beautiful background there. Where are you today? 

[00:00:05] Dr. Rogu: Today I'm in Pompano Beach, Florida. I just bought a Tundra over here and I came down to visit it. And I think Dr. Kressley is on today. She seems to be always in Florida. 

[00:00:15] Dr. Kressly: Well, I happen to be at the Jersey Shore right now, but that is a background from Sanibel.

[00:00:21] When I can't look out the window and see the gulf and the egrets and shells, I like to, at least in my background, pretend that I'm there. Because it is the place that grounds me so that I can get energized to take on the world whenever needed. All right, so 

[00:00:37] Dr. Rogu: today's topic is an interesting one.

[00:00:39] It's one that Dr. Sue Cressley knows very well. And the topic is, as a physician leader, what's a physician leader's role in empowering their medical teams to success? So Dr. Kressley believes that all children deserve access to well coordinated, patient centered medical homes. And all pediatricians, including medicine and [00:01:00] surgical specialists, deserve resources, payments, and support to meet the needs of their patients and their families.

[00:01:06] So let's take it away and talk about leadership today. So, Dr. Kressley. What do you think is a good leader? What does a good leader look like to create great culture? 

[00:01:18] Dr. Kressly: So first of all, this is a great topic and thanks for having me Herb and George, but I think that people sometimes think when you talk about leadership and culture, that only happens in large organizations.

[00:01:30] I don't care if you're a one, a solo doc with a single staffer creating some leadership, which then really helps. To motivate and inspire the team to fulfill the goals of your organization is key or else people just show up and it's a job and they go to work it. It helps people focus on the why. Why are we here?

[00:01:58] Why do we come to work? [00:02:00] What is what? What? What is the reason behind the tasks that we are sometimes feel like are overburdening, burdening us. 

[00:02:08] I think having a leader to remind people and guide people to and help them find the why for the organization. But it has to go all the way down. It has to go to every individual. Good leaders not only lead from the top, they meet every team member where they are and inspire them on the journey ahead and sometimes lead from behind. 

[00:02:29] Dr. Rogu: When you have a good leader that will help to establish a good medical culture in the office. But in training, medical training, we usually have that militaristic hierarchy where you have this captain, the general, the captain, the private or the senior resident, chief resident, senior resident, junior resident, and intern mentality, and people are not you know, they're afraid to speak up sometimes, they just follow orders.

[00:02:56] Dr. Bravo: Yeah, well, that's an outdated model. So, what would you say [00:03:00] are key strengths of a leader? What's your, so as a leader. For example, who do you admire as a leader? 

[00:03:08] Dr. Kressly: Some of the most impactful leaders I think are people who are very human and really work alongside their team.

[00:03:16] So if you really want to, one of my really awesome leaders. Is mother Teresa. She led by example, always by her why met every single human along the way where they are and helped them with hope and seeing a better tomorrow. I can't think of a better way, especially in pediatrics.

[00:03:40] For us to realize that every person in every human deserves compassion and to be met where they are, and how do we give them hope so that we can lead, lead together the second person actually came out of and I'm saying this today because I recently read a book about the two first ladies and Eleanor Roosevelt [00:04:00] she, she was a force to be reckoned with but didn't have to do it in your face.

[00:04:04] She often did it in very subtle ways and she did never needed the credit for it. She always pointed to the people who were being lift up lift lifted up. She didn't point to herself for for creating a better future. And so I think both of those qualities being willing to see every person and value every person.

[00:04:26] , and give them hope and then also being willing to color out the side, the lines where it needs to be done but empower everybody , and we had this conversation on LinkedIn recently, I think that. 

[00:04:39] Great leaders empower their teams. I don't have all the answers. I'm frequently not the smartest person in the room, and that's okay. I like to celebrate other people's expertise and experience. So empower their teams. And then when teams succeed, I like to step aside and highlight the team that really did the [00:05:00] work even in my own practice when we had rock star ratings for well visits and care gap closing. That wasn't me. I wasn't the person who was every day calling people and convincing them to come in for the value of a, a well visit. That was my nursing and team. So when, when we got paid for performance bucks, It went a significant chunk of that went to their pockets because it was their work, their work and I rewarded them.

[00:05:27] I also think that when something goes wrong we tried to do an a D. D. H. D. improvement project early on in when people were doing, making sure kids had follow up, et cetera. And it failed miserably. And I said, mea culpa. It's too soon. You don't have the right tools. We don't have the right reporting. I didn't give you the right time. This failed because it's my fault. I own that. We're going to set it aside and come back to it at a different time. So I also think great leaders take the blame when things don't go well. 

[00:05:59] Dr. Bravo: [00:06:00] So those are wonderful observations. So I'm going to dig a little deeper, George, just for a second.

[00:06:05] If you have not read this book, it's called The Mothers of America by Kofi Roberts. And it highlights all the wives of all of the fathers of America and what influence they had and what grit they had and how they changed the trajectory of history, not only of this country, but humanity.

[00:06:26] It's a great read how powerful these women have been in our history since 1776. You have three things, Sue. Humility, compassion, and nonviolent communication. 

[00:06:40] Dr. Rogu: From what I understand then, a great leader will help to establish and develop great culture within a practice, and then that would lead into medical practice excellence.

[00:06:51] Is that right, Sue? 

[00:06:52] Dr. Kressly: Let's go back to the culture piece, right? Because you culture is a mindset and there's 2 [00:07:00] pieces. Well, maybe 3 pieces to it. 1st of all. It has to be model, right? You can't mandate that everyone's going to be compassionate to your patients. You have to model and that includes when your team is suffering because there's something going on in their personal life.

[00:07:20] You can't say. Suck it up, buttercup. The phones are ringing, right? Like if you're gonna, if you're gonna want to have a compassionate culture, you have to model it. Secondly, you have to give people the infrastructure to live the culture. If you say you want to give compassionate care, but you're chronically understaffed, you can't, you're not giving people the infrastructure to be able to live your culture.

[00:07:44] Then you have to connect. that culture to a personal level for every person of your team. You can't just man, mandate your culture. 

[00:07:52] But it's interesting you talked about excellence. I think that the problem is that's a hard word for a lot of people [00:08:00] because excellence is defined differently by different stakeholders. What are the payers think excellence is? Oh, giving us more money to line our pockets because we came in under budget. That's not my definition of excellence. And if you ask the patients they would say that I was treated with respect and I was not only provided medical care, but I was cared about and cared for.

[00:08:23] I also think that excellence is a journey I've decided I used to wrap this into quality improvement, like a quality mindset, but I've turned it into what I'm now calling developmental excellence. Right. We expect our patients. to develop differently over time. We expect the excellent performance of a three year old's drawing to look significantly different than a six year old, right?

[00:08:49] And we're all still developing, right? Like, we're all changing as we get older and at the tail ends of our careers too. And so what I'd like to think about this is that we're [00:09:00] always achieving trying to do our best With the tools that we have and where we are in our life journey, a practice starting out is going to be at a different developmental excellence than a practice like yours, George, who's been around for a long time yet. You are always innovating and looking for new and innovative ways to be excellent to your patients and, and I think excellence happens when you align your mission, vision, and values and your culture, and you actually are doing the work that you intend to do wherever you are in the developmental journey of your organization.

[00:09:46] Dr. Rogu: I remember back with my practice when it started back in the sixties, they started as a solo practice. One guy, two gentlemen, three doctors and back before vaccines. So visits were not a problem. There was no insurance [00:10:00] visits were not a problem. They had lots and lots of volume. And I remember one of the senior senior guys, he had a motto that would say, believe it to be opposite of what you say.

[00:10:09] We don't believe in quality. We don't believe in quality. We believe in quantity. But that can only go so far. You can't do that. It's going to self implode. So if you continue, as a leader, if you, if you believe in that mentality, then you'll never develop a good foundation to a practice, which leads us into the next question.

[00:10:27] How can effective leadership create a solid foundation for a medical practice to success, especially when dealing with a pediatric office? You know, that foundation, if it didn't change in my practice, I think it would have imploded. 

[00:10:41] Dr. Kressly: I think that the foundation can't be built on concrete.

[00:10:45] Medicine changes too much, right? We have to be, we have to be like skiers up on our knees with our knees flexed, right? Or up on our feet with our knees flexed and looking ahead at what the avalanche and the, and the moguls are in front of us. [00:11:00] And we also should really consider. I would be willing to bet that that gentleman who was looking about the business models and it was all about quantity, bring people in, let's serve the more people.

[00:11:09] And it was probably well meaning let's let's serve more people, but at some point you have to save yourself. And I think we don't do this enough is okay. I have this mission, vision, what are the downsides? What's the unintended consequence of having this? Let's explore this in a 360 view. If I'm the patient, if I'm the payer, if I'm the community, if I'm the nurses, like if I say that I wanted to have more volume, like what are the unintended consequences?

[00:11:39] Because I think it actually makes you refine your culture, your mission and your vision. And that's only words. Unless you explain, so a good leader doesn't just throw that up there. Here's our vision statement. Let's unpack what that means to everyone in the room. How do you think other people outside the room will perceive this?

[00:11:59] What are we not [00:12:00] considering if we, if we really do this? That doesn't mean it doesn't end up being your vision statement. It just means that you are better informed and you look out for it. So in your case, where you were trying to see too many patients, if that happened during the triple demic, Like you, there were a lot of patients you couldn't serve because like you were drinking from the fire hose.

[00:12:19] Right. And so if somebody had says so, at what point is too much too much. And then what do we do when we have to make distinctions about who we're giving care to and who we're not allowing to come in. Oh, well, we didn't really think about. So let's think about it, right? Let's have an alternative. But before we are there and have to react and pivot quickly, let's think about deeply and good leaders don't only see where you've been, where you are, but they have about four ways to see where you're going in the future.

[00:12:55] Dr. Rogu: But I think when you have an effect, a leader that believes in [00:13:00] quantity, not quality. It creates a, some kind of like a negative culture because you get a lot of turnover between patients, between physicians, between nursing staff, secretarial staff, you're just replacing another body in the chair.

[00:13:16] Dr. Kressly: Well, you're back to task driven healthcare delivery, right? Not serving the needs of the, of the patients. Yeah, 

[00:13:25] Dr. Rogu: we suffered from that also in the past where we had so many people coming. You, you train people and they left, you train people and then they left, so now we're trying to train them to do good quality and not let them, not have them leave, I learned in the MBA school, when people quit, they don't quit their organization, they quit their bosses, and their boss is the leader, so the leader is bad, he's a bad boss, they will quit and they will leave you.

[00:13:52] Dr. Bravo: I got two comments. I have to jump in one. You can do quantity and not quality [00:14:00] and have a good culture and be profitable. That's a Walmart model. Does that translate into health care? In some circumstances, it may be okay. For example, public health. It would be much more effective if we went into the school the first day of kindergarten and did the PPD on everybody in every school in one day nobody would lose anything for it and we would still achieve the same goal than having each individual kid go to the pediatrician's office to get their PPD.

[00:14:30] But second of all, there's a difference between quote unquote a boss and a leader. Not all bosses are leaders and not all leaders are bosses. And people often forget that there's a huge difference. For example, Sue right now is not a boss, she's just a leader, but she's a tremendous leader and doing a tremendous job at what she knows how to do very well.

[00:14:58] But she's not a boss. [00:15:00] And she models this leadership by being humble. Compassionate, passionate, and not using what is Kathleen's term, violent language, and trying to meet everyone where they're at. The patient, the payer, the academy, the politicians, the pediatricians, the pediatricians in the hospital, the pediatricians outside the hospital. That is a true picture of a leader in my mind. What do you think, sue?

[00:15:32] Dr. Kressly: Thanks for that. I have to say that I enjoyed this part of leadership much more than being a boss. Because part of my bleeding heart wants to help everybody and sometimes you have to make hard decisions where you're when you're the boss, because you have limited resources.

[00:15:49] Sometimes you have to say, I wish I could, but I can't. And I hate to say that, but it's the reality of limited resources and anyone who thinks that we live in a world with limited resources is [00:16:00] kidding themselves, no matter where, no matter what you do in the world, but to meet other people where they are and understand their journey and where and inspire hope.

[00:16:10] I think that's a really part of where I am at this point in my career because so many of our colleagues just have become so downtrodden that they don't have any hope. And I want them to first reconnect with the compassion that led them to medicine, especially pediatric medicine. Like we went into this cause we love kids, right?

[00:16:30] We want to celebrate them. We want to lift them up. We want to empower them, right? How do you connect there again and then give them hope to sort of help them see a better future and a better tomorrow? And that's going to take some hard advocacy. With more resources and getting more respect for those of us who do pediatric work and, and that's not for everybody. And that's where I am. And we'll push the envelope where need be in the right conversations. But I, I [00:17:00] like this leadership piece better than the boss piece at least at this point in my developmental excellence journey, 

[00:17:07] Dr. Rogu: Resources are very important. Even as a leader or a boss or whatever. Medicine is indeed a business. We could be Mother Teresa, we can see everybody for free. It's not going to pay the rent. It's not going to pay the salary to the doctor. 

[00:17:22] Dr. Kressly: No, I agree. But so here's the thought thing that the leader boss needs to do. They need to use their resources most wisely and have it and define what, what problem you're gonna solve and what impact you wanna have, right? Mm-hmm. , we wanna have a profitable business and we wanna serve the patients of our. Our practice and our community to the best that we can. Let's acknowledge there's limited resources. And where do we have the most impact? And what are the things that we're going to have to let go? That's that's a hard thing for many leaders is to realize that this while I want to fix this problem and do it this way, I simply don't have the resources to do [00:18:00] it and to take resources away from other care workers.

[00:18:03] Would diminish this. Look, people are struggling with telehealth, how to embed it into regular practice, right? When we're still getting paid better and we figured out more efficiently how to put it into an exam room

[00:18:16] I think we're getting there and people are getting creative or people who want to take a mental health integration. I get it. I want to take it too, but we can't scale ourselves out of this problem. And so we have to decide. . What's the narrow scope that we have the resources to put our toe in the water and figure out how to do it efficiently, effectively and in an impactful and meaningful way to all the stakeholders in the world before we just open up the door. And we burn out , the people on our teams. Who say, Okay, so you have this culture, but you didn't give me the infrastructure and the resources to live it. So now that's where that moral injury, I know what I should do. I know what I want to do, but you did you cut off my arms and, and made it impossible for me to do that.

[00:18:59] [00:19:00] We have to be smart about, look, we budget our own, checkbooks, right? Like we make hard decisions based on priorities. If you want to ask people what matters to them, not ask them. If you want to know what matters to people. Ask them to see or show them your checkbook and your calendar, because people can really, they can talk priorities till they're blue in the face, but it's where they spend their time and their money that really shows you what matters to them.

[00:19:26] Dr. Rogu: Yeah, but for systems and hospitals, Herbert's going to like this one. Systems and hospitals deal with budgets and resources and in the pediatric department world. They don't generate the money that a cardiac surgery department generates for orthopedics. And what's happening is they're closing the ERs, they're closing the pediatric department the clinic and they're just shutting them down. And this is happening across the country. 

[00:19:50] Dr. Bravo: Yeah, that's a problem as well as the maternity wards being closed across the country. Again and I don't want to speak too much about this issue today. [00:20:00] These are conversations that need to be had. In the public arena on the hill with a senator and the congressman, and we have to accept that democracy decides my perspective. It is that it is foolish and dangerous not to have the infrastructure to provide care for pregnant mothers and mothers that are delivering babies. And that it is foolish to spend 500 on a biological while we're only paying pediatricians. Less than 500 if they're on fee for service or nine months of care of an infant or 300 if they're on a Medicaid, 50% of Medicare.

[00:20:43] That is a foolish lack of investment in the infrastructure of this country. And I might die before it comes back to bite people you know where, but it's going to come back to bite us. But if we don't have this conversation in public [00:21:00] where everybody can give their opinion and there's going to be pain.

[00:21:04] We will not change that problem, , I'm more interested with Sue, what is hope? How do you build hope? How do you, express hope? Cause it's an attitude. How do you do that as a leader? So people have that in their tool bucket. 

[00:21:24] Dr. Kressly: So first I think that you have to give them space to express their pain. As healers, we want to fix stuff. And sometimes the answer is that we just have to be there in that uncomfortable place and let people sit in their pain and sit there with them alongside them so they don't feel like they're alone. Because if you sit there in their pain with them long enough and they've, and you give them a hand. All of a sudden, not feeling they feel like someone cared enough to really listen. They were heard [00:22:00] and that they mean something and have value. And then if you just reach out your hand and you sit there and say, you're not alone, sometimes that's just enough. to have a spark that the world is not against me. It is not hopeless. Somebody cares about me and, and listen to me. Maybe there's a chance if you talk about suicide prevention, if you talk about depression you know, there is a lot of good studies that show that just giving people a place to listen and be heard is the first start step in healing.

[00:22:37] That doesn't mean having a suggestion box in your break room where you can tell people how to do better. It means being human and having human conversations. And that takes time. That little spark of hope, and then people need to see somebody you know, I always say you can't see it.

[00:22:58] You can't be it if you can't [00:23:00] see it. So if there is someone who is practicing and delivering care, that's bringing them joy, like. Kathleen Wania, right? Like she really recreated, she said, I need to create this better space for me and the families that I'm privileged to serve. And so listening to her and it's, nothing's perfect. This is the journey we talk about. You're not going to get up in nirvana and, and, and, and stay there. You're, you're going to seeing people and hearing people that inspire you. , so it's feeling valued and. Feeling like someone cares and as your hand, seeing where you might go. And then someone giving you the first two steps because people can be inspired by Ted talks and they can see people succeeding. Like people used to say that to me all the time when I'd give quality improvement talks. Oh my God, Sue, I can't be you. And I'd be like, okay, here's the two things you're going to go home and do this week. Give them a step forward because otherwise it's too daunting to see all the [00:24:00] way to the end. 

[00:24:01] Dr. Bravo: To your point and Like you expressly, wonderfully but the male brain in what George was alluding to, which was, you know, when we were residents, you know, I still have a pair of boots I walk with, you know, they gave me a musket and they said, go into the fire, which way, the way the bullets are coming, son, that's go, right.

[00:24:26] That is not a very effective way of growing humanity. And the most difficult part for me, I don't know for anybody else in this conversation, is that I feel like a dad when the kid scrapes his knee. I want to sit down and cry with him, knowing that this is nothing. This is just part of growing up, but I want that scrape to go away and for him to be happy and enjoy the rest of his day.

[00:24:53] And then I move to do something and that's our mistake. All I need to hold is that child for a little [00:25:00] bit. I acknowledge that , yeah, it stinks when you scrape your knee. When he's done crying, then maybe we can go get a lollipop or we can go get a popsicle and go to the pool and enjoy the rest of the day.

[00:25:14] But the need for the male brain to act is something you have to stop yourself from doing. Would you agree, Sue? 

[00:25:21] Dr. Kressly: So I don't think it's just the male brain. In medicine, we're, we're, we're driven to fix stuff, right? And, and sometimes that healing piece of medicine, which we got pounded out of us somewhere along the line, we forget, which is just to be present.

[00:25:38] in what's experiencing. So, you know, people say, where's all this money come from, Sue, that you're talking about? Well, you know how I feel about this, and I'm getting old. So we have, we spend way too much money at futile end of life care that we should be putting humanity there. Right. I read a fascinating article about CPR you know, the [00:26:00] conversation about do not resuscitate orders.

[00:26:01] And most physicians are like, yeah, no, if like, please, if I'm an extremist and there's no hope of recovery, if I'm still going to have end stage heart failure or cancer, like don't crack my ribs and make that be my last song take me home and country roads. Right. But, but we don't do enough. We, we are treating our patients at the end of life differently than we want ourselves to be treated.

[00:26:26] And we have to really look at the money there and say, where is it best spent? That is not effective use of resources and everybody knows it, but people don't know how to stop themselves. So I think it's very interesting, maybe the geriatrics and pediatricians that the world have to get together because I think that we are really driven by the same humanity of doing what's right.

[00:26:49] to serve that chapter of our lives, right? It's, you know it's where it needs to go. We're driven to fix stuff. And sometimes the answer is, is [00:27:00] just to sit there. It's interesting. People come to me and say, okay, so now we're supposed to screen for social determinants. I can't fix poverty, right? You don't have to fix poverty. The first step is acknowledging that poverty impacts health. 

[00:27:14] Dr. Rogu: It certainly does. In the hospital system, most of the people that work in the hospital are hospitalists, adult medicine, internal medicine people. And what do they do? They fix things. And truthfully, it takes a really long time to get an event to explain to the age, the family.

[00:27:33] Well, grandma, you know, she is 90 years old. We could give her another month or two by doing this invasive procedure. And you have to sign off over here. And there's a lot of emotion and turmoil. And then there's the medical legal aspects of, you know, the whole situation that, you know, they're afraid of getting sued if they don't do anything. So the poor doctor is stuck in the cash claim too. 

[00:27:53] Dr. Kressly: And that's how the hospital is making money. Let's be honest. Yeah, of course. So, to go back to your whole hospital [00:28:00] shutting down what I think are necessary community services. I think good leaders in those organizations should get together and start to point out to them they are not fulfilling the mission that they say they are.

[00:28:12] You are not living the mission and you are not giving us the tools to serve our community. And call them out. Because what's happening is the people, the leaders, the decision makers now are really driven only by the money, not by the community need. And that's not how most of those most of those hospitals were founded.

[00:28:34] We always knew that maternity and pediatrics was a loss leader for the organization. But it's how people decide where to receive care for the other hip replacements and cardiac. Surgeries. So, we're letting the bean counters carve off, cleave off with a hatchet necessary community services because they are told to [00:29:00] reduce spend or increase profitability without looking at the whole, they are treating only the wound they can see, not the whole 

[00:29:10] humanity of the of the person of health care in front of them.

[00:29:15] Dr. Rogu: I think this is done by design because with all the hospital consolidations and in Pennsylvania, so you probably have seen it more than we've had. Every the hospitals are consolidated because of efficiencies or whatever. Economies of scale, it always started with a shut down the maternity shut down the pediatric shut down the pediatric hospital.

[00:29:34] That hospital then gets taken over and get shut down and die. The hospital that I was born at St. John's. Hospital in Queens, that's a condo now, the community for years. 

[00:29:47] Dr. Bravo: There's a lot of community hospitals, unfortunately, who have abandoned maternity care and pediatric wards and pediatric ERs, and they're still functioning and they're more successful.

[00:29:58] It's easy to name [00:30:00] call and call them bean counters and say that they're not following their mission. However, the reality is that there's two forces, one called JCO. Which I am more allergic than to most other organized medicine organizations. If you want to see the name, the face of the mafia, just go on, just go on the JCO website.

[00:30:24] They're a worthless organization. The second one is called the U. S. Congress. It is regrettable, and it really should give us shame, all of us. That 50% of our children are near or at the poverty line. That means 50% of moms have to be at near or poverty line because that's how they get enrolled in Medicaid.

[00:30:46] That means , and the politicians, because we have not told the mothers of this country this, we have not told this story, have decided a Medicaid mom delivering is worth [00:31:00] half of what a Medicare patient's worth. A child is worth half of what a Medicare patient's worth. And they have not properly funded this infrastructure.

[00:31:13] So the hospitals have to deal with the low margins or losses in every delivery because it is underfunded. And second, JACO. Intervenes and says, and so do the state levels through their certificate of needs. So, in Virginia, if you're not doing 300 deliveries a year, your maternity ward gets shut down because they think you cannot deliver quality and they're probably right.

[00:31:43] And Jayco has drilled it into our head, two great sins of Jayco, give narcotics to everybody so they go home happy. And second, if you don't just do tons of volume of one thing, you can't do it right, and [00:32:00] you should get out. 

[00:32:01] Dr. Kressly: Herb, let me just tackle that from this perspective. That is failure to look at the unintended consequences of what you think is the right thing to do. That is failure to look at. Okay. So if we say that volume is necessary, and we closed down maternity wards here, here and here, where parents where families who don't have any transportation supposed to go, nobody took the time to fully consider the unintended consequences of action. And I and regarding the Congress and society.

[00:32:34] We are. The vast majority of congressmen and the regular people and our colleagues not in pediatrics. Would be astonished to believe that 50% of kids in this country are covered by Medicaid or CHIP. This is a conversation that now as leaders, please join me. We need to have everywhere we can. Because people [00:33:00] who I tell that to are like, Sue, those numbers are wrong.

[00:33:02] I'm like, no. It's horrifying. Why aren't you listening? And we have to raise voices. And this is where I love your mom army, right? Because moms feel like they're the only one. No, you're not. You're the majority. Like let's rise up together. Let's talk together and let's take teachers with us because Lord knows that the, these kids aren't also, are also getting shortchanged in education in multiple places.

[00:33:30] So let's figure out how we lift kids together and if we lift up society's value of kids I think that we take along the value of the pediatrics and supporting infrastructure. I still think that it's not a bad idea to reduce the voting age to two because we would we would have things much more representative or let moms vote on behalf of each of their child and themselves.

[00:33:57] But, but that's going to take longer and, you know, inmates don't [00:34:00] like to vote themselves off the island. So let's join forces and raise voices. 

[00:34:04] Dr. Rogu: , let's move on to something that's more happy. Nurturing the pediatric talent. How can a leader help retain top tier talent, both in the physician department, nurses, secretarial staff? There's a leader that has to do this, not just an office manager hiring, right? How do you do that? 

[00:34:22] Dr. Kressly: It's very similar to Hope. Meet them where they are, learn about who they are, make sure they're seen, heard, and valued, ask them what their value is, ask them what they'd like to accomplish, ask them their why, why they come to work, and then be able to champion their voices in places where decisions are made, and pave the way for them.

[00:34:43] To to lead with their heart and to and really to practice their craft with dignity, right? They, they want to be able to practice the way that they are driven to serve that may be getting out of the way that may be giving them the right [00:35:00] infrastructure that may be getting rid of toxic, influence. That's one thing is Peterson's were hard to do. Sometimes when there's a boil or a cancer brewing in our organization, we make excuses for why we don't cut it out when it's small. And then we have metastasis and it's hard, right? Like you have either overwhelming sepsis or metastatic cancer.

[00:35:20] So sometimes you can shave that off a little bit and, and re redirected. And sometimes you have to just. Say, this is not a good fit. And, and that's hard for us, especially when we're struggling for workforce, but having the wrong people with the wrong attitude really is, is worse than working short and scaling down your expectations based on your available resources.

[00:35:44] Dr. Bravo: I'm going to hit this one and you guys are not going to like it, but sometimes that also applies to parents. Who bring their kids and they just destroy your office staff, you know, they just ruin the whole day. And it's better to say, we're so sorry, we won't [00:36:00] tolerate that.

[00:36:01] And, you know, we would love to take care of your kid, but we're not going to do that because it ruins our ability to work for everybody else in a good mood and with all everything we want to give them. And that is really hard because we feel like we're abandoning the child. 

[00:36:17] Dr. Kressly: So, yeah, no, no, no. It's the right thing to do. And I will tell you my when you have an empowered staff, they know you have their back. Sometimes even when I'm not sure they're right. It's the right thing to do. I don't question when they come to me and say, Sue, this mom just swore at me and, and, and, and spit on the, whatever I don't say, well, let's have a meeting and talk about it.

[00:36:46] I'm like, okay, I go, I'm like, it's mine. I'm I'm the leader. You go take a walk, do what you need to do. I have your back. They will absolutely, if you [00:37:00] empower staff to do the right thing and you tell them what it is. You have to have their back and that's part of the whole leadership journey. And sometimes that means setting limits.

[00:37:09] Look, families are very much like toddlers, just like our spouses and our government officials. Sometimes you got to set limits and say, I'm sorry. We're respectful. We respect humanity here. You did not treat my staff with disrespect. I would love to provide care for you, but I can't and uphold the values of my organizations.

[00:37:30] So we will give you emergency care for 30 days. Here's where you can seek other care. I wish for you a heart big enough someday to treat every human with respect, because that's what we try to do in this case. 

[00:37:44] Dr. Rogu: Right. So let's take a look over, Herb, to data and measurements. You're a data geek, and you're going to love this one, right, Herb?

[00:37:51] Yeah. 

[00:37:52] Dr. Bravo: So I think it's very important, and I'm not, I don't know if you're familiar with what happened. With one of the Korean [00:38:00] airliners that crashed. So, this is been a subject of much study at business schools. In the late, late 1990s, there was a accident in a Korean airliner because the captain was just an absolute jerk.

[00:38:15] And the language that he used was demeaning. And it, and it made everybody in the plane. Not want to speak up and so the culture he created with his crew was one of I am the smartest man in the room And no one dare ask me or question how I'm doing things. So as they were lifting off the First mate saw that the gauges weren't showing the right altitude in the right path And he said, the gauges aren't working, and he said, you know, the captain said some snooty comment of, you know, that, you know, I know what I'm doing, you just don't know how to read the gauge, soon after they crashed.

[00:38:59] [00:39:00] And that has been used as a example of how your words have tremendous impact in the quality that you provide in your practice. So, if your attitude is, I went to, I don't know, Harvard Medical School, and I'm the smartest guy in the room, I don't know why you're bringing that up. The data is wrong. That can't be done. Why would you bother me with that? And that's all you can say to every suggestion that's brought up in your staff. The result is going to be reliably, nobody's going to inform you of trouble ahead. 

[00:39:37] Dr. Kressly: Yeah, so, so that's really impactful. And I would say in medicine, the house of medicine, we're really not good about policing each other. We have to, we have to keep the patient at the center and challenge and When we, you know, like the airport, if you see something, say something. I think if we see something, we have to do something. And that's on behalf of our colleagues and the patients we [00:40:00] represent. Do you know who the smartest person in most exam rooms is?

[00:40:03] Dr. Rogu: The mom. The mom. The mom, yeah. 

[00:40:05] Dr. Kressly: You got to stop to listen. That's her kid. She lives with them. We see them for 15 minutes at a time. Yeah, 

[00:40:12] Dr. Bravo: I mean, I see these moms with four kids and with a fourth newborn. I'm like, what do you need from me? I mean, you, you, you've raised three and you're on your fourth one. You know, 

[00:40:24] Dr. Kressly: except now she's really playing zone defense, which wait, wait a minute.

[00:40:28] We can learn from that because what does she have to do? She's limited resource of herself and her time and her love and her ability to interact with each kid. So let's learn from moms and figure out how do we resource and give. equitable care to each child. All of those kids are not getting exactly the same thing, but she is in the moment giving the kids what they most need to be able to help thrive and feel loved.

[00:40:58] And it will not look the same. I remember [00:41:00] my parents saying to me, it's like, there is no even Sue, like there's no fair. Like we're going to give you what you need at the time. And it's micro decisions in the moment trying to give the kids what we need. We can learn a lot from moms of multiple children, how to deal with limited research.

[00:41:16] Now you just gave me a great idea. I want to start, I want to start start a parent advisory panel for you want it. Somebody want to volunteer their practice. And get them all together and say, all right, you moms who are juggling way too many schedules and too many kids and priorities. This practice has the same problem. How do you get through the day? And let's try to apply some of what you have so beautifully instituted in your home to this practice. That would be 

[00:41:42] Dr. Rogu: a project. I think you're supposed to do that for PCMH certification, have like a parent advisory. 

[00:41:49] Dr. Kressly: Yeah, but people give that lip service and put somebody on and whatever. I actually did that and listened to people and it, and, and I, and I threw out two of my QI projects and did something else [00:42:00] instead. and 

[00:42:01] Dr. Bravo: the, when I talk about measuring the quality, one of them I don't know how to do. And, but the other one is fairly simple, so. When your language is toxic, what happens is I'm talking to your physicians all the way down to the people that clean your office.

[00:42:21] They either, they shut down and their productivity slows down until they've had enough of it and they leave. So when I get in 

[00:42:30] Dr. Kressly: until, until they, until they check out, they phone it in until they check out, but you don't have a high performing team member at all. So, 

[00:42:39] Dr. Bravo: you know, so one, one metric is your turnover practices that lose physicians all the time.

[00:42:46] Some of you can't avoid it, right? I'm married to. The CEO of Oracle and they want him in California, they want him in London. Well, he makes a million dollars, I make a hundred. We're going to go [00:43:00] there, okay? But so I think turnover is one. And two, I would think is, we know what it costs to replace an employee and it's something in the ballpark of a hundred to two hundred percent of their salary.

[00:43:15] So if you have a pediatrician that's making two hundred thousand and they leave. That, that year you're going to take a 400, 000 shot. 

[00:43:23] Dr. Kressly: Yeah. So Kathleen, when he talks about by language, I don't think it has to be violent to just be as impact negative, negatively impactful, just has to be negative, right?

[00:43:33] If you hear negative language all day long, you're in a mindset of downtrodden. The hope goes away, all of that sort of stuff. So two things. We have to call each other out on it. And I don't care where you are in the hierarchy. I don't care if you answer the phone, scrub the floor, or you're the owner of the practice, people have to be, somebody has to be empowered and it's gotta be someone who, you know, like I'm always that person who says that in the [00:44:00] organization, cause.

[00:44:01] I have the least to lose. If you want to fire me, go ahead. Over that. But the second piece of it is people are really bad about seeing themselves and introspection from that way. And I think teaching introspection to physician leaders is an important tool. One of the ways you can get there and Kathleen talks about this with her compassion.

[00:44:24] And if you read compassionomics, there's a compassion survey. And it's not that you thought you were being compassionate. It's the receiver. The family thought you were treating them with compassion. It is amazing when you ask people like, do you all know somebody in your practice or your organization?

[00:44:43] Who's probably not a very compassionate physician and everybody's hands raised because we all know somebody. And then I ask people, how many people think that's you? And nobody thinks it's them. Well, if we all know somebody. It is some of us, and we have to [00:45:00] be willing to be open to having that introspection to look at how we're received by others, whether it's your staff or your patients, it's ideally it's both.

[00:45:10] Dr. Bravo: And then the third metric, which I have no idea how to measure this, but Dr. Dean does, Wendy Dean does, is we need to start measuring physician well being. So, we have an early indicator in our dashboard of this physician is feeling too burdened by a lack of resources. How can I model or give, you know, if I can't give him more resources, model behavior, how can I shift his schedule, what can I do to improve his well being or her well being so that we are all successful and I don't lose another physician?

[00:45:48] I don't know what the metric is, but that needs to be talked about in quality. 

[00:45:53] Dr. Kressly: So to me, it's taking the temperature, right? Right. There's some people who are covering it, you know, [00:46:00] 99. The nurse sends you home. That's not a fever to me. But but there's taking the temperature of how you're doing. And it may be for that person who's just on the urge to ask them what it is about their administrative burden.

[00:46:13] That is. It's killing them and it's the straw that breaks the camel back back and maybe you give them that. Maybe you give them a scribe because they can't write notes. Maybe they can't stand entering answering portal message. So you give them a nurse practitioner to play intermediary. Maybe you, they don't like reviewing labs on the computer, right?

[00:46:33] Whatever. Find that little thing that is just the thorn in their side and remove it and give them breathing room until you can really get them to a place where they can heal. But when you're about to explode or to check out and no return then, we need to figure out how to take that temperature and find them as an early warning signal.

[00:46:55] I agree. Yeah. So 

[00:46:56] Dr. Rogu: this goes into our next topic. Challenges and solutions for [00:47:00] how leaders can help physicians to overcome their problems. And I've, I've been seeing this in my practice. I have different generation of doctors. Everybody will blame the EHR. That's the cause. The clicking, the workflows, the process and the, but the physician will always, always say, too many patients, too little time.

[00:47:21] I mean, there's no way you can spend one hour with each patient. And truthfully, I don't think they want to stay with you for one hour either. So, you know, the resolution that they have is to direct primary care and spend as much time as I need with the patient. I think we have to develop systems to make the physician's life better.

[00:47:39] Things that are repetitive, things that happen all the time. We've done this in our practice, where we've created these little videos that are sent out in a text message before their visit for ancillary guidance, what vaccines you'll be getting, what will happen at the visit. People are appreciating that, and I tell the doctors, use the videos, ask the patients, did you see the videos that said, The RBK doctors would like you to watch [00:48:00] this if you have any questions, but no, they will continue to go down that 50 checklist of bright futures until they get to the very end of it after an hour.

[00:48:09] They wonder why they're behind schedule and then they have to document. 

[00:48:13] Dr. Kressly: Yeah. So let's speak. How do you get them to change? So first of all we have to understand that physicians are really averse to change for very good reason. We've spent a lot of time creating muscle memory so we don't make a mistake and so patients aren't harmed.

[00:48:27] And so when things change, physicians get really nervous that they're going to harm a patient because it's new and I'm not used to doing it this way. So we have to acknowledge that first of all. Right. Then we have to figure out a way again to show them a different way and let them practice. One of the things we don't know, we don't really know what happens inside the exam room with our colleagues, right?

[00:48:52] And so just showing people how other people do it. If you have somebody who's good at getting out of the room let that other [00:49:00] person just be ascribed for that person for a minute and just, just see it. There also is good data. Physicians like data that say, If you ask a patient up front what they hope to get out of the visit today and set the agenda up front, it shortens the visit.

[00:49:19] People are scared to do that. You're here today for ear pain. That's, that's what your nurse wrote. Instead of saying, what are you hoping to get out of the visit today? My mother in law insists this kid needs antibiotics and I don't think she does. All I want you to tell me to validate my concerns.

[00:49:36] Awesome. I don't have to spend 10 minutes telling you why I don't need antibiotic. You're already in my camp, right? Or if they have 62 lists, you say, man, that is about a two hour visit and I don't think we have time to do this justice. Let's chunk it up. Give me the top two things you want to adjust today, address today.

[00:49:55] Let's do them. And then let's figure out how to [00:50:00] schedule or have portal message or set some time to do the others patients leave feeling satisfied, but we must work with them. Bright futures was never intended to do that entire checklist, George, but that's what people think. The thing that bright futures people forget is what takes precedent and every visit is the parent and family and patients priorities.

[00:50:22] Ask them first, what do you want to do today? And then you don't get stuck with, oh, by the way, on the way out the door, which kills everything. Absolutely 

[00:50:30] Dr. Bravo: right. So I learned from that psychiatrist, what, what may I do for you today? Well, Sue, this has been a wonderful conversation as always. We'll see you soon, hopefully in the beach.

[00:50:42] Dr. Kressly: Yep. Al empowering all those awesome pediatric leaders to give better care to their kids. Keep doing it. Thanks for having me. Keep doing 

[00:50:49] Dr. Bravo: it. No one's going to do it. We'd love to. Yeah, Sue's our gal, if I can say that in today's world without getting shut down. 

[00:50:57] Dr. Kressly: That's good for me. Bye guys. 

[00:50:59] Dr. Bravo: [00:51:00] Bye.