Category: Physician Burnout

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Recommended Books:

Cutting for Stone

When Breath Becomes Air

Practicing Excellence

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Linkedin

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http://practicingexcellence.com/

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Taking a Break from the Physician Grind with Stephen Beeson, Founder of The Clinician Experience Project at Practicing Excellence

Welcome to the Outcomes Rocket podcast where we inspire collaborative thinking, improved outcomes, and business success with today's most successful and inspiring healthcare leaders and influencers. And now your host, Saul Marquez.

And welcome back to the podcast. Today we have Dr. Stephen Beeson. He's a nationally recognized author, physician, and speaker, who's provided approaches for developing clinicians and leadership for hundreds of medical groups and hospitals across the country to transform care for patients and those providing care. Today, it's super important to have a background of somebody that has been there and done that at the frontlines both as a clinician and as an Administrative Executive. And Dr. Beeson is just that he's board certified in family medicine. He's been practicing with Sharp Rees-Stealy Medical Group in San Diego for over 18 years. His tenure with the medical group. He was selected by Sharp Healthcare Leadership to serve as the Physician Director for the Sharp Experience and Organizational Commitment to serve and operational excellence. He's an author of a book called Practicing Excellence and it's also the name of the practice that they are doing this work in. And so it's a true pleasure to have Stephen on the podcast. I want to open up the intro for him to fill in the gaps of anything that I may have missed. Stephen welcome.

A great thanks Saul. I'm delighted to be here and I think the only other gaps outside of the fact that I'm father of two and a husband is we have recently done some really compelling work in helping and supporting and engaging and supporting physicians in something called the Clinician Experience Project with thousands of clinician members across the country and just super excited about the kind of results that we're seeing and what happens when you help and support and create practice conditions that allow clinicians to love the work that they do and do it really well. So super excited about talking to you and dive it in.

Thank you. Yeah the work you're doing is truly impactful you're working with some big names. And really the feedback that I've heard from your work is inspiring. What is it that got you into health care to begin with?

Well you know when I was in high school I wanted to be a musician. I was playing trumpet my parents really like imagine a living doing that and after I finished high school I actually spent some time with my uncle Dr. Robert Hazelbrook who's a neurologist and he told me about a day in the life of being a clinician and what that's like and the ability to diagnose, manage three, and sometimes cured disease and the master endeavor of learning a body of knowledge that allows you to make an impact in patients lives. And I was so intrigued by that day in a life that in that moment, on that day I switch from music to a biochemistry major at University of California San Diego now and the journey was on.

That's a big shift.

Yeah.

That's a big shift but a good reason to do it. Wow. So the years have passed and now you've sort of given from the front line and now you're taking a much more macro approach through what you're doing. Obviously there's a big void in what clinicians need and tell us how you're feeling that?

What we've seen and dating back to Around 2001 I began and was selected and appointed to coach trained to develop clinicians in a very competitive health care marketplace driven by consumers and patient choice. And we as a group were in bottom decile in terms of patient experience. I was tasked with how do we help and support clinicians to provide better care to patients? And I really for the next 15 years became a student of what are the things that physicians need to really become the kind of clinicians that they want to be and really what I discovered that drove me into the work today is that clinicians make massive sacrifices to get into positions that they are and they are 90% of all clinical activity. There are 80 cents of every dollar spent in healthcare. Their principal cultural drivers and the fundamental skills by which to make health care better are never developed. Yeah and we're in a field now where over 50% of clinicians despite what I consider to be the most beautiful precious profession that there is anywhere to make a difference in the lives of those we serve. And over 50% are experiencing symptoms of burnout. And I consider that now to be a life calling. And again the night is for the work that we're doing now is helping supporting clinicians to do the work extraordinarily well, to connect to the patients they serve, to collaborate with their colleagues beside them, and to lead in a way that brings the very best of each other, and to use that to drive not only patient experience, harm reduction but also at the end of their day week month year life. They look back over their shoulder and they say this is everything I hoped it to be and that's the essence of really what we're trying to do is help drive the clinician experience and the clinician experience being the gateway to all the other health care imperatives in front of us and harm reduction, patient experience, patient loyalty, clinical excellence, and all those things.

Well you know I think this is a truly inspirational work and very mission-driven. Folks when you're in the airplane and you're getting ready for takeoff, the flight attendant will tell you to put the oxygen on your mask before anybody that you love that's next to you. And really when we're working with clinicians it's so important that their gas tank be full and the work that you're doing Dr. Beesob is truly dedicated to keeping their gas tank full. So as health care leaders listening to this, looking for ways to improve, what would you say an example of something you and your organization has done to help say a health care executive improve that leadership culture for physicians?

It's a great question and I think it's a complicated answer. What are the conditions and what are the personal approaches that clinicians take. So they love the work that they do. And we we are able to create and generate and execute on something called the clinician experience. We define the clinician experience as this is everything I wanted it to be. I provided the kind of care that I believe in were driven by evidence for getting great outcomes. And on Sunday night before a clinical day, I'm excited about tomorrow. That's the essence of the clinic. The question is what do we have to do to help support that? And if you look at that data in terms of what are the greatest influences on the clinician experience. First and foremost it is the conditions in which physicians work under it's not their personal resilience or their endurance. It's the conditions that clinicians work under so as I speak with leadership teams there is a composite of what leaders do where clinicians say I love it here. Number one they are out front and authentic, leaders are deeply committed to what's right and best for patients and they communicate in a way to their clinical body that connects with physicians values system so when we as leaders say hey you need to improve your patient satisfaction scores and see as regulations say we have to do this that and the other and the payer feel that saying we have to see more patients for less money. That's not what engages us to change. Well it prompts us to sit in the back seat cross our arms and say this is not at all what I thought was going to be. But the leadership approaches of outfront authenticity of a commitment to what's right and best for patient, we found in our research that the clinician experience project that when physicians feel as though their leaders are deeply connected to what's right and best for patients the probability of burnout among those physicians is 4x less than what leaders are not led by that nature. So number one they're outfront authentic and deeply committed and communicate in a way that's consistent with the position value system. Number two they tap clinicians to help solve care delivery problems. They don't mandate, dictate, and bullhorn solutions, they say "here we've got a challenge in regards to or start times you've got a challenge in regards to patient access. We've got a challenge regarding variance around diabetes composite. What are your best ideas? For us to innovate solution?" So they're tapping team intelligence and accessing the innovation of clinicians at the front line as a way of leading the organization. So physicians feel like I've got a voice, I can participate, and we're getting results done together. That's what leadership teams do. The third thing that leaders do where clinicians say I love it here is they simply appreciate their clinical team members, they recognize them, and they appreciate them, and they take it to a hospital as to get a phone call from their CEO who was rounding up patients up in the hospital and said hey I'm talking to patients and talking to nurses about your multidisciplinary round. You're making more impact than you can imagine and what patients and team members are saying about the difference that you're making and as this hospital was telling me the story of the CEO calling her she was welling up some it's just it's unreal to get appreciated for the work that we do. So what do we do to advance a clinician experience, we lead in a way authentically committed to what's best for patients. We tap the ideas of clinicians at the front line. We appreciate them and we take on administrative burden, reduction, as an imperative of leaders. We found in our research that when physicians believe their administrative burden is not reduced and taken on by the leadership team, connectivity to patients from their angle is reduced by nearly 80% and organizational cynicism doubles. So our ability as leaders to say what are the tasks that we can take off their plate to allow them to practice medicine? So four things reduction of interim, administrative burden, appreciate your clinicians have their ideas to innovate care solutions, and communicate in a way that's storytelling and authentic regarding what's best and right for patients. And we're seeing unreal results when leaders do that sort of thing.

That's amazing. So folks here's the blueprint for creating that engaged culture. It's tough right. I mean you could have a blueprint but how do you follow through? So a question for you is what are you guys doing and maybe you provide an example Dr. Beeson of how you guys have helped an organization take this blueprint and make it actionable?

No for sure. And again part of what we've done we've formed this community called the clinician experience project which is a learning collaborative community with over 15,000 clinician members across the country with some of the biggest names in health care and they're using this community as a catalyst, as an enzyme to allow the individual clinician to better connect with patients in the exam room meaning when I am interacting well with my patients. My love for the game is fundamentally different and driver number two is we help teams form communities a collaborative culture and getting better together. The clinical micro system level where they feel like there's esprit de corps and getting better together. And the third channel is what we talked about initially is developing leaders with skills to best engage their teams so we're using the Clinician Experience Project as a programmatic progression of how do we better connect, do we better collaborate, and how do we lead. We consider those things three legs of a stool and a stool does not stay on two legs.

Right.

If you've got positions that are deeply connected to patients with toxic top-down administrative leadership you're going to destroy that clinicians. So they, the clinician as we've defined it is about connecting, collaborating, and leading, and then we use the clinician experience project and we've got fantastic results out of Kaiser Colorado, fantastic results and Centera Medical Group with measured outcomes and improvements in things like patient experience, physician engagement, and attrition reduction in documented case studies.

So that's outstanding. Congratulations that's huge. And one thing that I really love about your approach Dr. Beeson is the database approach, your outcome-based approach, you're documenting everything, you're doing the research, you know this isn't like a feel good exercise although part of it is but you're really getting the data to back up what you're doing.

Yeah I know for sure. I mean I think it's you know data is the currency of healthcare today. And if you're not in metrics it's not it's not why we're we're not here to move metrics. But it's a consequence when we better connect with patients and better collaborate with each other and lead more effectively. There's quantitative metrics that will move. One great example we're doing some work with Beth Israel Deaconess and they had one of their strategies was building a community and a collaborative sense of we're in this together. And what they had done and with some are worked together was started monthly meetings where they carved out one hour work clinicians and clinical team members could get together and talk about solutions to care delivery problems. And they did shorts rounds where they had a chance to sort of take a bow for what they flailed on that we do create vulnerability. And I'm not alone. And that once a month one hour they were able to reduce physicians sense. I went to women's organization from 78%. They had a five year plan that 70% of their physicians when to leave within five years that's not good. And just a year later got it down to around 35% and drop their physician turnover from 30% to 5%.

That's amazing.

So these are the kind of quantitative impact of what happens when we build collaboration and when we give physicians tools to connect with patients and when we start to lead in a way that brings the very best of our teams. And you know we are so deeply committed to helping clinicians love their work. And as you said you get to take care of your own oxygen mask I mean the literature on what happens to physicians and the care that we deliver when they're burned out from medical error to cost of care to patients were poor to med mal risk to care coordination and all those things that we consider to be imperatives all are significantly harm. But I think most importantly you use clinicians us we have sacrificed everything to get here personally, professionally, financially. And you finally get to the place that you dreamed of and 400 of us commit suicide because of the misery that we're experiencing. I mean it's like it's hell we can't have that in this sacred profession of impacting lives, collaborating with each other, and making diagnosis. I mean it's got, it should be great. And it's not. And that's why we're here.

That's amazing. That's amazing and I love your commitment to it. So as you've built this and you've been thinking about these problems and the solutions to these problems you've been implementing things you've written a book on it. What have you learned a setback that you had as you were trying to implement these things? What did you take from that setback that now has become a principal of your organization?

Well I think that if you had a 7 or a podcast we could talk about all the mistakes you engaging physicians. What I have learned and the learnings emerge from mistakes is that almost every clinician that I've ever met wants to be a great clinician and is deeply committed to it and sometimes it's so covered up by burnout and dismay and cynicism. But I think I think one of the big mistakes that I was part of number one not including physicians in key decisions and skipping that step and telling them what they need to go do. I think that would somehow be faster better easier if that had massive consequences and delayed improvements wherever I've been witness to literally years and the other mistakes that I think was part of of getting giving physicians data on patient experience, patient complaints, and even clinical data and not giving them the tools by which to improve that data. I think it's cool. I've shadowed over 600 physicians. We have 15,000 I have never met a physician who could articulate why the patients say what they say about and they go I'm not what. It's just unfair to give data when and again data is important without giving specific tangible. I can move the needle on this by virtue the solutions that I know I have. And so that was a big learning.

And now it's a core principle. It's one of the three stools, are one of the three legs of the stool.

Absolutely and a library of human contentment is mastery. Now our ability to accomplish achieve, improve, whether it be a golf swing, playing the banjo, or better connecting with their patients or leading in a way. I mean when you watch leaders learn skills that allows them to practice team intelligence and watch the innovation and enthusiasm emerge, leaders go "I wish I would've started doing this 10 years ago.'.

Yeah.

It's easier and we're getting better results and everybody's on board. I'm dropping the bullhorn. It just doesn't work. And so but one of the things that I wanted to mention was all this composite of the clinician experience we have recently year leaders I would love to get their feedback. I wrote in my next book it's an e-book called The Clinician Experience which is the data and the approach for how do we tackle the Wellness Challenge. I would love for your...

That's really interesting.

Yeah.

So the best way folks that we can get you to engage with this e-book. Check out the show notes and I'm going to get a link from the team over there Practicing Excellence, Dr. Beeson's team. So you could get a copy of this book when you go to outcomesrocket.health/excellence you're gonna find that link and we'll provide a way for you to leave feedback for Dr. Beeson and his team.

Yeah that would be fantastic. I mean we're trying to start a movement here of supporting those that care for others. And then when we do that everything anything becomes possible.

That's outstanding. So we're getting close to our end point here Stephen, let's see if you could give us a little bit of maybe a sneak peek on a project that you're focused on today and I'm gonna roll into the lightning round part of the podcast and will conclude.

That sounds great. One of the things that we do within the clinician experience project is we partner with organizations and we ask the question "what are the things you want to achieve and how can we help you as a enzyme to help and support clinicians to get there?" And we've got some really exciting projects that we're working on with some great organizations on how do we reduce harm and the safety culture. We've got some really exciting things coming in high reliability and patient connectivity and leadership development that we're doing in placing inside the clinician experience project and beginning to expand and deepen our research and assessing and tracking and measuring the clinician experience and always looking for collaborative partners to figure out innovative solutions supporting not only the clinician experience in terms of I love what I do but also clinician contribution to I now know how to better connect collaborate with my teams and provide really great care.

That's powerful stuff. Now for the folks that want to engage with you and your team Dr. Beeson where did they reach out?

Yeah I think probably the easiest way is just you know our website which is practicingexcellence.com and you can get a hold of any one of us through that site. And the book will be there for free as well. And I think with it the e-book in particular it begins to ask a different question. I mean there's thousands of publications now on burnt out. We've seen it, heard it. We wanted to ask a different question which is "what is present in organizations where clinicians really truly love what they do?" Of course there's tremendous overlap in addressing the principal causes of burnout. No question but the connect collaborate lead and all the literature and research behind it is very compelling. And again it's a different way of looking at a very high profile threat to American health care which is the wellness of the care team. And again we'd love to get some banter and chatter regarding how to approach this challenge differently than I put it on e-book.

Thanks for the invitation. Folks go to a practicingexcellence.com to get access to that, for the show notes outcomesrocket.health/excellence. You'll find all that there. All right. This has been a ton of fun Stephen. We're in the lightning round okay so we're going to build a syllabus with four questions for the listeners on what it takes to be successful in the business of medicine and happiness and medicine. I got four questions followed by a book outside of the two that you've already written that you recommend to the listeners. You ready?

Okay I'm ready.

Alright. What's the best way to improve outcomes?

Lead your teams with relentless passion.

What's the biggest mistake or pitfall to avoid?

Lead by a regulatory call to action.

How do you stay relevant despite constant change?

Tap your team and their innovations in what they think you should do differently to create value for the patients and serve together.

Love that. And what's one area of focus that drives everything in your organization?

Commitment to making a difference in the lives of others. Constantly telling stories about impact this is to be accessible.

Yeah stories are powerful. What book would you recommend to the listeners?

Well one of my favorite books is Cutting for Stone. It's a fascinating story about empathy and the journey of surgeons and how it's really one of my favorite books I've read it twice.

Oh that's a good book.

That's my recommendation. When Breath Becomes Air. I think it's another great book if your, that was hard to read but it's a beautiful, beautifully told story.

Awesome. Some great recommendations there and a great syllabus for us to use as a framework to drive the things that we're doing. Again find the syllabus and the full transcript go to outcomesrocket.health/excellence. This has been fun and what I love Dr. Beeson is if you could just leave us with your closing thoughts and then the best place for the listeners can engage.

I think the most important thing we can do as leaders in health care is to care for those that care for others and you know we frequently skip that step and we go on to the list of things on our scorecards that we're accountable for. But I can tell you in 15 years of experience and hundreds of healthcare systems and tens of thousands of clinicians that the headwind and friction of getting those things done is overwhelming when clinicians are overwhelmed, burdened, and not supported. So help and support and engage your clinicians, make their wellness a number one imperative. And when we do that, harm reduction, clinical variation reduction, patient experience, talent retention, top and bottom line, can all follow. And without that all those things are really hard.

That's amazing.

And again you can practicingexcellence.com. We'd love to help and support anybody that's looking to take the. We want to take care of our clinicians journey. We get some incredible stories that are emerging and data that's coming forward when we do that right.

So they have it folks. That is your call to action. If something today resonated with you, take action, don't wait 10 years like Stephen mentioned. Do it now because the results will be a ripple effect of greatness. Stephen this has been great. I really appreciate your time and definitely looking forward to staying in touch.

All right thanks Saul. Appreciate it.

Thanks for listening to the Outcomes Rocket podcast. Be sure to visit us on the web at www.outcomesrocket.com for the show notes, resources, inspiration, and so much more.

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Mindfulness and Behavior Change from an Addiction Psychiatrist with Judson Brewer, Founder at MindSciences

Recommended Book:

The Art of Racing in the Rain by Garth Stein

Best Way to Contact Judson:

Judson's website

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Mindfulness and Behavior Change from an Addiction Psychiatrist with Judson Brewer, Founder at MindSciences

Hey Outcomes Rocket friends, thanks for tuning in to the podcast once again. As a leader in health care, you have big ideas, great products, a story to tell, and are looking for ways to improve your reach and scale your business. However there's one tiny problem. Health care is tough to navigate and the typical sales cycle is slow. That's why you should consider starting your own podcast as part of your sales and marketing strategy. At the Outcomes Rocket, I've been able to reach thousands of people every single month that I wouldn't have otherwise been able to reach if I had not started my podcast. Having this organic reach enables me to get the feedback necessary to create a podcast that delivers value that you are looking for. And the same thing goes if you start a podcast for what you could learn from your customers. The best thing about podcasting in healthcare is that we are currently at the ground level, meaning that the number of people in healthcare listening to podcasts is small but growing rapidly. I put together a free checklist for you to check out the steps on what it takes to create your own podcast. You could find that at outcomesrocket.health/podcast. Check it out today and find a new way to leverage the sales, marketing and outcomes of your business. That's outcomesrocket.health/podcast.

Welcome back to the broadcast. Today I have an outstanding guest. His name is Dr. Judson Brewer. He's the Founder at MindSciences. Judson's a thought leader in the field of habit change and the "science of self-mastery", having combined over 20 years of experience with mindfulness training and scientific research therein. He's a Director of Research and Innovation at the Mindfulness Center and Associate Professor of Psychiatry at the School of Medicine at Brown University. He's also a Research Affiliate at MIT. A psychiatrist an internationally known expert in mindfulness training for addictions. Brewer has developed and tested novel mindfulness programs for habit change including both in person and app based treatments for smoking, emotional eating, and anxiety. This gentleman has a ton of experience. He's been featured on many media platforms like TED, Al Jazeera, NPR, the list is long. What I want to do is open up the microphone to Judson give his little introduction and I want to welcome you into the podcast.

Thanks for having me.

It's a true pleasure. And so Judson just curious is there anything in that intro that I missed that you want to highlight to the listeners?

Sounds great.

Awesome man and guy like you you're just like "Man how in the world that I do all that" right it's like the time flies, you do amazing things and here you are but I'm curious what got you into the medical sector? What was that spark?

It's been a long and winding road. But it's interesting I was an organic chemistry major in college and one that all of the premeds hated because I actually loved organic chemistry and wasn't planning to go to medical school but was really fascinated by these molecules that made up life. And I remember learning about putrescine and cadaverine and things like that in my freshman chemistry class which you can guess where you know where those come from and just you know I started looking at some of the professors. I'm looking at the things you know they kind of, some of them had pigeonholed themselves to studying very small molecules for their entire lives and I was thinking yeah I had this itch to really make whatever I was doing relevant to helping people and so decided to do it MIT Ph.D. program where I could continue with my love of research but also do medical work at the same time and ideally dovetail that to and that's that's kind of what got me into the medical field and then and bringing out together with my own research field.

Love that, love that. So you were the guy that screwed up the curve and made everybody else study harder.

Maybe in one class.

I love it man. You could definitely hear in your voice that you're passionate about your work. And I think that tends to be the secret sauce to success. And anybody that has a meaningful and value adding career. In your perspective Judson, what would you say a hot topic that needs to be on every medical leaders agenda today?

Burnout is just one that comes to mind. I could give you a list of five. But burnout and anxiety, big one.

It's a big issue. And so how and what should they be thinking about? How are you approaching this in your work? Give me some insights.

My work focuses on behavior change and I was fascinated,first fascinated with these molecules that made up life and then started getting fascinated with like how stress affects the immune system and you know doing a bunch of molecular biology work in my Ph.D. program and then really got interested in how humans learn habits and how it can change them and as some of that work was progressing. You know we were doing work with smoking and with the emotional eating I started to see and learn in the literature that anxiety can actually be a learned behavior. You know certainly there are a lot of genetic influences that can predispose us to anxiety but we also can reinforce it in a way that I hadn't really thought about before you know as an addiction psychiatrist I've certainly treated a lot of people's anxiety and our treatments hadn't really gotten really hit the mark. You know it seems like benzodiazepines can be helpful but they're recommended to only be used for a short period of time because they can be addictive etc.. You know the SSRI's aren't showing to be particularly great. And so there really aren't that many great medications that specifically target anxiety which actually makes sense. You know it goes back this learning system where we learn anxiety goes back all the way to the most basic process where we learn how to basically remember where food is now it's called a reward based learning or operant conditioning. And so the anxiety piece is really interesting to see how that can contribute for example to physician burnout and what you can imagine if we're anxious all day it consumes a huge amount of time and energy and our mental space we just don't have that extra bandwidth to be able to be with our patients or to be leading our teams or to be working, working effectively in general. And so you know at the end of the day we go home exhausted and then just think "oh no I've got to do this again tomorrow".

Yeah. It's a big deal. And I was just at a conference recently. Showing the stats on just job satisfaction, would you recommend this field to your kids? You know for physicians and yeah definitely glaring statistics that aren't very encouraging for the future med student or even the clinician working in this space. Anxiety contributes to burnout. What would you say some things that you've been recommending or your research has been finding that helps not be as burnout.

Well it's a good question and we've been approaching this. You know if I put on my research I had.

I want to know why people get burned out and why they form anxiety habits and so have been approaching that from a translational perspective or we look at brain activity of folks to see if we can understand what brain networks are involved in these things and also have been doing intervention development where we can pair specific targeted treatments that actually focus on the payroll mechanisms underlying anxiety. So that's how I've been approaching it and it's been a really interesting journey. And I chronicled a bunch of this stuff in my book because it really talks about I should say that this premise underlying learning underlies a whole lot of things everything from being addicted to social media to distraction. It's even getting caught up in anxiety and there's a lot of neuroscience that's now being discovered around this. So we've really taken a targeted approach where we can map out how excess habits are formed and then have been focusing actually specifically on mindfulness training and testing it to see if it can help people with anxiety. We actually just finished a large I should say a pilot study with a bunch of anxious stressed out physicians to see if you know one if we could give them a novel you know mindfulness training delivered through an app because physicians are pretty busy and we don't want to give them more things to do and if we give them mindfulness training can we help them change their anxious habits. And does that even have a spillover effect on burnout like as like burnout inventory.

Fascinating. A domino effect right.

Well yeah well we found well first off it was one of ease. Unfortunately it was one of the easiest studies for me to recruit people to because there were so many stressed out physicians. And we've actually got about a 50% reduction in anxiety scores using this generalized anxiety measure and then more interest. Well that was great. But more interestingly we found that we got about the same level of reduction in burnout scores. So people were reporting that they were less calloused for their patients that were that callousness reduced by 50%. And these effects were lasting overtime even beyond when they were using our EP based mindfulness training. We developed this app called unwinding anxiety as a way to help them work with anxiety. So you know it really interesting just by helping people learn how their anxiety is formed that's how we introduce the practices and then how they can use awareness or mindfulness practices to work with them helps them not only with the anxiety but also these other things that anxiety effects like burnout and callousness. So it's a really interesting journey.

That's awesome yeah. And so folks Judson wrote the book, The Craving Mind. From cigarettes to smartphones to love, why we get hooked and how we could break bad habits. It's a fascinating read. I'll put a link to that book and the show notes so you could take a look for yourself. It's one that is worth listening and watching his TED med talk to because he also dives into somebody's concepts within his Ted med talk. I'll put a link to that in the show notes as well. So without a doubt very interesting and timely Judson to be talking about this. Can you give the listeners an example of maybe a time when you had a setback or maybe some sort of learning that you learned from something not going well? And feel like we learned better from those examples and why that happened and how you are doing things differently as a result?

How long do we have? Yeah I totally agree with you. I feel like falling on our faces really helps us learn more than succeeding at things especially if we can take every one of those incidents, incidences and instead of beat ourselves up for that which kids get to inhabit you kind of what am I. We can think of it as bowing to it as a teacher and asking "what can I learn from this?" and in that way instead of kind of closing down and walling often and thinking oh no we think wow that was crazy. What can I learn? So I'm just thinking recently you know when I've struggled with just even simple things because I'm trying to think of something particularly challenging that came up recently where there was a clear hard to even think of what I count as a failure because everything I've kind of started to look at everything is like wow it's not really a failure. I learned more from that than anything else. So just learning how to work with a larger team for example. So moving from leading my research team to leading a center was has been really challenging and just looking at the importance of interpersonal dynamics and really taking the time to carefully interact with folks and make sure that everybody feels like they're seen and heard. That was I'd say I can certainly say I've fallen down a number of times there where I tend to just go in my mom calls it business mode. Let's get to the heart of the problem. Yeah that's good. And it's really especially for some people it's really important to start with "hey you know how you doing?" Let's check in. So I've certainly fallen down a number of times where it's like wow you know this interaction just needed to start out differently because I didn't know or hadn't learned to really check in with that interpersonal piece first before we kind of rolled up our sleeves and got to business. So that's one example on our personal level. And it's something that I continue to learn from.

Great example. Yeah yeah good yeah. And you know it's one thing that all of us can do better. We recently had a HealthCare Thinkathon is our first annual meeting in Indianan Apolis and one of the speakers was Nick Atkins. He's the pink socks movement guy. I'm not sure if you know who that is or not but he's all about this experience that you're just talking about you know that. This I see you, I see you before let's get into it. And acknowledging people's presence. We did a little exercise. And what was cool is that at the end of the meeting this is one exercise that was really so simple resonated with so many people and it's because you know taking that extra moment to just make that personal connection really makes a huge difference in the overall relationship and then the result or seeking to drive through whatever projects were on. So I think it's such a great example.

That sounds wonderful and just to add to that that actually may fit within these forward based learning paradigms. So if we think of always looking to external things to make ourselves feel better whether it's eating a cookie or doing whatever, we can actually turn toward these intrinsically rewarding things like just connecting with somebody because that's always available we don't need to go and buy connection at the store. And it feels really good so that can be reinforcing in itself that connection piece. That sounds wonderful.

That's a really great idea. Write that one down folks say as you know and we don't realize how powerful are the things that we do are and how much of a habit they are on this topic of habits, are you grabbing a cookie, are you smoking, are you drinking to satisfy something and then all of a sudden it becomes a habit. And are the things that you doing on a day to day basis creating that anxiety and that burnout. Definitely something worth thinking about in your own mind. And big thanks to Judson for helping us think about this. So Judson what would you say is an exciting project or focus that you're working on today?

One of the exciting projects that we're working on is really moving into the digital therapeutic sphere. So when I first started doing research on mindfulness training this is about about a decade ago we were delivering mindfulness in person and we were finding pretty good effects you know like actually we get five times the quit rates, gold standard treatment for smoking. Yeah. So we were like wow this is actually work. And we were looking to see how you could disseminate these types of things and it's really challenging to have therapists follow him annualized treatment and about the time, this time iPhone's were starting to come out that Android phones and we were thinking you know people don't actually learn bad habits. In my office but so that context dependent memory actually loses some of its or the treatment loses some of its juice because it's not really in context. So I started thinking well maybe we could deliver this in context and I could package my office and deliver it to them via their phone. So we started really exploring this and have subsequently developed apish training for smoke it's called craving a quit for eating when called eat right now. And then one for anxiety. And just last year the first FDA approved digital therapeutic it came out. So this field just exploded with this new term digital therapeutics. And we've kind of been exploring...

What therapeutic was that? Do you remember which one it was?

I forget the name of it but it was put out by Pear therapeutics in Boston. Oh yeah. It really ushered in and is ushering in this new wave of treatment where you know called MHealth or mobile health where you can deliver high fidelity, scalable methodologies, and a lot of them don't have good evidence yet but some are getting really good evidence bases to the point where you can get FDA approval. We're seeing this type of stuff with our atbase training. So that's probably the thing that I'm really excited about right now is to see you know how we can be part of the forefront of this movement and just can't figure out the best ways to deliver training via digital therapeutic. And on top of that the best ways to deliver help people understand how their minds work and deliver mindfulness training is an effective therapeutic ranging for habits like smoking to eating to anxiety.

You're doing outstanding work Judson and you know I think that there's definitely a lot of promise to the digital therapeutic. So keep doing what you're doing man. It's exciting. And again the promise on what's on the other side of this is huge for the people that need it.

Thank you.

So getting close to the end here. Judson let's pretend you and I are building a leadership course on what it takes to be successful in medicine. The one on one of Dr. Judson Brewer. So we've got a syllabus. We're going to put together here with four questions on this lightning round followed by a book that you recommend to the listeners other than the Craving Mind.

Okay.

So question number one. What's the best way to improve health care outcomes?

Listen to our patients.

And not. Totally agree. What is the biggest mistake or pitfall to avoid?

Jumping to conclusions or making assumptions without looking at all of that information or taking a good history and getting a good differential diagnosis.

How do you stay relevant as an organization despite constant change?

Awareness is always relevant. Kindness is always relevant. The work that we're doing is never gonna go away.

I love that. What is one area of focus that should drive everything in a health organization?

I'm going to say kindness and really supporting, creating a supportive environment.

Wonderful. What book would you recommend to the listeners Judson?

Oh man there's so many great books. One that I particularly love is called The Art of Racing in the Rain and...

Very cool.

On the perspective of a dog.

Really.

Yes. For anybody that's curious.

I love this, I love this. Folks, The Art of Racing in the Rain. Check this one out. Obviously dovetails nicely into Judson's work. This has been great for anybody that wants the show notes as well as links to the resources that we mentioned. Please visit outcomesrocket.health/brewer as in Dr. Judson Brewer you'll find all of that here. Before I conclude Judson I'd love if you could just share a closing thought. And then the best place where the listeners could get in touch with you.

Closing thoughts. Learn how your mind works. It will be very helpful. I certainly found that for myself and the folks can find me on judsonbrewer.com or at Brown University. But the judsonbrewer.com should have all of my contact information and some of the things we've been talking about.

Outstanding. Judson, it's been a pleasure. You've encouraged better habits more mindfulness and we're excited to keep up with what you do in your latest work. So thanks for making the time for us now.

Thanks for having me.

Hey Outcomes Rocket friends, thanks for tuning in to the podcast once again. As a leader in health care, you have big ideas, great products, a story to tell, and are looking for ways to improve your reach and scale your business. However there's one tiny problem. Health care is tough to navigate and the typical sales cycle is slow. That's why you should consider starting your own podcast as part of your sales and marketing strategy. At the Outcomes Rocket, I've been able to reach thousands of people every single month that I wouldn't have otherwise been able to reach if I had not started my podcast. Having this organic reach enables me to get the feedback necessary to create a podcast that delivers value that you are looking for. And the same thing goes if you start a podcast for what you could learn from your customers. The best thing about podcasting in healthcare is that we are currently at the ground level, meaning that the number of people in healthcare listening to podcasts is small but growing rapidly. I put together a free checklist for you to check out the steps on what it takes to create your own podcast. You could find that at outcomesrocket.health/podcast. Check it out today and find a new way to leverage the sales, marketing and outcomes of your business. That's outcomesrocket.health/podcast.

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Creating a Hub For Physican Innovators with Lisa Rotenstein, Co-Founder at CareZooming

Thanks for tuning in to the Outcomes Rocket podcast where we chat with today's most successful and inspiring health leaders. I want to personally invite you to our first inaugural Healthcare Thinkathon. It's a conference that the Outcomes Rocket and the IU Center for Health Innovation and Implementation Sciences has teamed up on. We're going to put together silo crushing practices just like we do here on the podcast except it's going to be live with inspiring keynotes and panelists. To set the tone, we're conducting a meeting where you can be part of drafting the blueprint for the future of healthcare. That's right. You could be a founding member of this group of talented industry and practitioner leaders. Join me and 200 other inspiring health leaders for the first Inaugural Healthcare Thinkathon. It's an event that you're not going to want to miss. And since there's only 200 tickets available you're going to want to act soon. So how do you learn more? Just go to outcomesrocket.health/conference. For more details on how to attend that's outcomesrocket.health/conference and you'll be able to get all the info that you need on this amazing healthcare thinkathon. That's outcomesrocket.health/conference.

Welcome back once again to the outcomes rocket podcast where we chat with today's most successful and inspiring health leaders. I really thank you for tuning in again and I welcome you to go to outcomesrocket.health/reviews where you could rate and review today's podcast because we have an amazing guest with us today. She is the co-founder at CareZoom. She's co-founder and CEO there. She's a physician practitioner at Brigham Women's Hospital. She's a graduate of the Harvard Medical School and she's also a graduate of the Harvard Business School known for being mad tech Boston's 40 under 40 in health care. She's a World Economic Forum Global shaper and she's previous director of I.T. and editor in chief at close concerns. She's got a really amazing background in health care and contributed so much. Her name is Dr. Lisa Rotenstein. And Lisa I want to give you a warm welcome. So glad that you've joined us and welcome to the podcast.

Thanks so much for having me today Saul.

It's a pleasure Liza, and let's talk about this Dr. Rotenstein, what did I leave out of your podcast introduction there that you want to share with the guests?

So I think you did a great job. I think you highlighted what I'm working on these days that I'm really passionate about. I'm a clinical fellow and a resident at Brigham and Women's Hospital and internal medicine and through that role have a chance to work on a variety of research and healthcare innovations that I'm excited to talk to you about. And you highlighted Well my work with CareZoom where we are aiming to democratize Healthcare Improvement and really make innovative health care accessible to everybody.

That's definitely one of the things that I really thought. Man, you know Dr. Rotenstein is doing some amazing things. We call it silo crushing here on the podcast and you're totally crushing silos with your CareZoom platform. Excited to dive into the details of that some more. But why don't you start by telling us a little bit about what got you into health care to begin with?

Sure. So I would say that what ultimately drew me to healthcare and kept me here is the really unique mix of the ability to work with people, think about their lives and then also think about biology both of which I love and a long time ago actually when I was in high school I had the chance to work at a free clinic in California where I had amazing mentors who are family medicine doctors who I thought were really effectively dealing with both the biological and the social aspects of treating disease in a church that was converted to a clinic every Wednesday afternoon and where doctors were able to provide free care after hours. So that's what started me on this path. And along the way what's kept me here is my relationships with patients who are inspiring and teach me every day and also experiences in diverse parts of health care and seeing how so many people are able to contribute from pharma to big hospitals and then people in the entrepreneurial world who are excited to make a change.

That's so interesting and it's those heart strings the ability and opportunity to be able to serve patients that is really what drove you into the practice and what's kept you here and a lot of other physicians too, you know. And in this system where we constantly have to reinvent the wheel, the opportunity to share those moments with patients becomes more difficult. So what an opportunity for you and your organization at CareZoom to do something about this. Can you walk us through what exactly CareZoom is and what you're doing?

I would love to. So CareZoom is an organization that is looking to exactly as you said break down silos and healthcare improvement. We are building a database of healthcare improvement recipes. You know the way you have a recipe for soup but rather a way a recipe for improving your healthcare system and we're starting in primary care. There are innovators across the country you know implementing new technologies in their clinics implementing diabetes prevention programs, new population health management programs and that information can be really siloed and difficult to share. So for example when I was in medical school where part of the passion for this started I was part of a project where we were looking to implement care plans and we had read in the literature all about how great care plans were for patients with complex medical problems. And you know we saw statistically significant results in the literature but when it came time to get information about how you actually roll this out in a clinic that information was harder to find. You go to conferences where people share their work. And yet the information is presented on a poster that then is tucked away somewhere that academic medical literature sometimes doesn't appreciate this kind of work the way it does pure research and on the other hand sometimes consulting is really out of reach for a lot of clinics and so we saw an opportunity to crowdsource the amazing work that people are doing and we're really excited to have started in primary care and to have projects as I mentioned related to diabetes, Behavioral Health, Medical scribes, all sorts of innovations happening all we've started on the east coast and are looking to expand. And then also to bring forward the identities of people who are doing this kind of work without a lot of recognition essentially in the trenches and these are nurses, these are doctors, these are social workers. So we're very excited to feature this work.

So interesting Dr. Rotenstein and it's awesome that you said you know what, I see the problem and I'm not just going to sit here and complain about it I'm going to roll up my sleeves and create something to solve this problem. And listeners, I really want to just highlight here what Lisa has done and I welcome you as well to do the same thing. If you see a problem don't just look at the problem like crash on the side of the road pull over and see what you could do because at the end of the day the fixes in our health care system are going to come from us. So the onus is on us so kudos to you and your team Dr. Rotenstein for taking the initiative.

Thanks Saul and I would say kudos to the people doing this work every day. And as I mentioned so we're going to be publishing this database shortly and we're also building an expert network because we feel like there and we've been told there is great value in peer to peer conversations. So we invite listeners to visit our site at CareZooming.com and to sign up to either be part of our expert network or get advice from our network of innovators.

That's awesome. What a great invitation. Listeners, take Dr. Rotenstein up on that, CareZooming.com. We'll also be leaving that link along with the transcript of our podcast and any other resources that are mentioned here in the show notes. So if you're driving don't worry about that you'll always be able to reference the show notes for that but it's simple it's CareZooming.com. So tell us a little bit about how you and your team there are creating results and improving outcomes by what you're doing your work there.

Yeah I would love to, then I'd love to tell you about our team at CareZooming and then I'd love to tell you a little bit about the work I've done at Brigham as well to create results in a similar vein. So we have already at CareZoom started connecting innovators across the country to each other. Just the other day, you know we got a request of somebody looking to take on a hospital improvement project and were able to give them some of the nitty gritty details from a variety of implementation projects that we have in our database. And we've also uncovered and featured work that hasn't otherwise made it into the medical literature and been able to publicize the identities of people who you know aren't publishing their work every day but really are doing valuable things on the front lines and have a lot to contribute to Healthcare Improvement. So I would say that's where our main focus is and that's what we're really excited about delivering. And on the flip side I would say that some of the most exciting work that I have done at Brigham and Women's Hospital focused on innovation has actually been in implementing I.T. tools into daily care. So one project that I'd love to feature which is a part of where the idea for CareZooming came from as well had to do with implementation of decision support tools into oncology care. And so you know I was part of a team that saw a need to improve prescription of short course radiation among patients with cancer and we had realized that although there were society guidelines saying that short courses of radiation were just as effective as longer ones in patients who needed radiation of bone metastases in busy academic medical center with many providers delivering care. There was real variation in how often this was executed upon and so we built a clinical decision support tool linked to the EMR to guide providers through the decision of how much radiation to give. And a year after rolling this out into daily workflow we found that appropriate prescription of short courses of radiation which are easier for patients to tolerate have less side effects and overall are thought to be more beneficial at the end of life. So the proportion of patients getting that had doubled and had increased significantly which is really exciting. So these are the kinds of innovations that I'm really featured on and looking to learn about from across the country.

That's wonderful and it's great that you're both aggregating best practices and you're aggregating innovators to help improve this waste of resources. So there's no doubt as you as you alluded earlier you know there's there's a ton of people doing so much hard work and they're oftentimes unappreciated. Oftentimes what they do is not replicated. Sometimes even within the same system. I'm excited to see what you and your team can do to make sure that those best practices get shared and applied to folks across the nation. So I love it. I think your work is pretty amazing.

Thanks Saul.

So let's take a look at sort of the history here and sort of what got you and your team to this point can you share with the listeners a time when you had a setback, feel like we learned a lot more from our setbacks and our successes. And then what you learned from that setback?

I would love to share it and I'll actually share it from something that I worked on prior to CareZoom. But that has definitely shaped the way that I have approached this particular venture. So when I was in business school we worked on several classmates of mine and I worked on an app. And we knew that there was a problem with people who had elderly family members aggregating their meds, understanding who all of their providers and getting all of their information in the same place. And we put a lot of resources into creating an app with a great interface and thinking about all of the people who could use it. And I would say that the place where we felt short was listening well enough to our end user and also thinking about how our technology would interface with end users daily actions. And so although we ended up having a great piece of technology when it came time to thinking about who would adopt this and who would pay for this. You know it turns out that people didn't really want another app healthcare systems taking care of elderly patients didn't want something they wouldn't plug into their EMR. And so it was an important lesson for my team and I to really listen before we started innovating that the needs on the ground should drive the innovation rather than vice versa. And that's something that I've taken forward and think about all the time with CareZoom.

That's amazing and really appreciate you sharing that. Dr. Rotenstein you know it's something that happens all too often. You know we get excited with with our ability to do something and we don't get that feedback from our users. And we've all fallen victim to it and I thank you for your courage for bringing that one up so that the listeners if you guys have not had a chance to really get enough feedback please do it because you don't want to waste time, you don't want to waste money before you put a solution out to market and then find out it doesn't work. Build it with your end users in mind and find out the other key that that Lisa mentioned to us is who's going to pay for it. What a great lesson. What about the other side of things? The successes. I know you've had a lot of successes very early on. Can you give us one of your proudest medical leadership experiences today?

I would love to. So I would love to talk about one of the studies that I did in my role as a clinical fellow at Brigham and Women's Hospital. So a team of my colleagues and I conducted a study of depression in medical students and we found after doing a meta analysis of studies worldwide that 27 percent of medical students were depressed, clinically depressed and that only a small percentage of them had sought treatment and that a significant proportion of them actually had suicidal ideation. And beyond the publicity that came around the study which was published in JAMA in 2016, I was most proud of the way that it changed conversation. I was excited to hear from my colleagues about workshops that were being held with medical students and other trainees to talk about depression, to talk about coping and also to see the response thereafter from institutions who are really examining the systems in which trainees were experiencing health care and how those could be changed. And it was just meaningful to see the ripple effect of that which I continue to see in my clinical training these days. You know I see doctors more often talking about wellness about mental health and really examining what we should be doing differently.

Absolutely. And I'm really glad you brought that up. We oftentimes forget that there's a whole population of medical students going through the same things that the physicians are going through. And if there's a way for us to start earlier, awareness is the key. And so, I love it. If there's a way to link to your study Dr. Rotenstein if you could provide that or somehow give me a link to share with the listeners I think that would be a wonderful one for them to read.

I would love to and I would say that our same team is currently working on a study of burnout and depression in attending physicians. And what we've interestingly found is high rates of burnout in the 30 percent range among the attending physicians and very similar rates of depression and attendings as in medical students. And as has been shown in residence previously suggesting you know what we might intuitively know that the working environment that you're in on a daily basis shapes both your experience of training and then also your mental health. What we're excited to show that that holds around the world across genders, across specialties and is something we need to continue tackling.

Absolutely. And so Lisa for the physicians, the physician leaders, the residents listening what message would you give to them?

I would tell them that there is not going to be an easy fix to this problem. With that there has been a lot of movement forward already. At least for trainee's work hours. There are a significant step forward, but it's something we have to be paying attention to and part of it from my perspective does have to do with wellness initiatives which many institutions are undertaking but it also has to do systems of care in which we work which is you know how I actually see all of my work linking together that on a daily basis. Your doctors are dealing with difficult electronic medical records systems. They're seeing patients who are still struggling through the health care system. They want to tackle chronic disease and often don't have the resources to. And so I believe that a big portion of ensuring physician wellness has to do with optimizing systems of care which is you know how I tie everything back to CareZoom and the health care system we want to have in the future.

That's great. And what percentage of that would help if you said you know what it's OK to talk about it. Like you're not superhuman and we don't expect you to be. Talk about it.

A significant proportion I would say. And it's getting easier to talk about it. But there is still a part of training where there are long hours and you have to tough it out and it's hard to say what part of that is a necessary part of training where you do have to have the stamina to provide care to patients in difficult situations versus a constraint of our system that has to do with financing and what resources we have to provide care versus we really could change and we need to talk about more openly on a daily basis and be constructive together as we think about this.

Totally listeners, if you're a physician you're not complaining you're communicating. And I think that's a big step in making this better. What would you say an exciting project that you're working on today is?

So I'm definitely excited first of all about CareZoom and I would encourage listeners who have done innovation work to get in touch, we would love to feature your work and especially as we build out our expert network to have you be part of that network. Something else that I'm working on at the Brigham currently is thinking about how to improve care for really complex patients during their transitions of care and when they're in the hospital. So working with several teams to think about how do we put together care plans to maximize how we take care of the 1% of patients who have multiple medical and social .. and thus actually account for 50% of healthcare costs. And how do we support these patients during their transitions of care? How do we have them go safely from the hospital back out of the hospital to the outpatient world? Maybe they'll go to a rehab facility. And how do we put in place systems of care that ensure that their outcomes are the best they can be?

Outstanding. Lisa that's super exciting and from the front lines doing some major silo crushing all the way to the straight of offices we got a crush these silos to continue making health care better for ourselves but also the people that we care about most, our children, our parents, our grandparents. And Lisa. your efforts here are extremely awesome and I just encourage you and your team to continue the amazing work.

Thanks. This is what gets me up every morning and what I'm passionate about. And so would love to hear from other people who are excited about this type of work.

Absolutely. So Lisa getting close to the end here. We've got the leadership course we're going to put it together right now. It's a syllabus. The 101 of Dr. Lisa Rotenstein. And so I've got four questions lightning round style for you followed by your favorite book and your favorite podcast. You ready?

I'm ready.

What's the best way to improve healthcare outcomes?

I would say leveraging collective knowledge and paying attention to all the different stakeholders and how they can work together.

What's the biggest mistake or pitfall to avoid?

Putting I.T. into health care and expecting it to change healthcare without paying attention to the system around the Information Technology.

How do you stay relevant as an organization despite constant change?

Pay attention to current trends in legislation legislation is always changing but it determines so much of payment and health care and also listen to the patient and have a laser focus on the patient because they're who we should be driving our efforts towards.

What's one area of focus that should drive everything in a health organization?

I would say improving healthcare systems which can affect as much of health as a drug can or even more.

What book and what podcasts would you recommend as part of the syllabus Dr Ottenstein?

I would listen to an American sickness by Elizabeth Rosenthal which provides a really great deep dive into the multiple players that affect health care from insurance companies, to doctors to hospitals. But I think does it in a really person focused way and provides vignettes that will stick with you and will remind you about why we do the work we do on a daily basis.

Super interesting recommendation and the book?

American sickness was the book in terms of the podcast. That's OK in terms of the podcast. I would recommend review of systems which is a podcast about improving primary care and it is actually now cosponsored by the Center for Primary Care at Harvard Medical School. Hairiness features people across the country who are changing primary care systems and also on a weekly basis highlights important literature not space so you can stay up to date in primary care improvement.

Outstanding. Lisa thank you so much for that. Listeners these recommendations are amazing and if you want to just level up I recommend that you check them out. We've got links for them. Just go to outcomesrocket.health/carezoom and you're going to find all of the resources that Dr. Rotenstein shared with us as well as her bio. The transcript, links to her business, links to the podcast, links to the book. Everything is going to be there but make sure you take action and go check that out and also take her invitation. Do some collaboration with her and reach out if you find what she's doing is interesting. So just want to say thank you so much Dr. Rotenstein if you can just leave us with a closing thought and then the best place where the listeners can get in touch.

Great. Thanks so much for having me. My closing thought would be that there is power in everybody involved in health care from the patients who use it on a daily basis to the people working in it to the scientists who are powering in and we have a collective responsibility I would say to collaborate to move things forward. The best way for people to get in touch with me is my email which I'll provide to Saul and will be on the website. You can also reach me on LinkedIn or Twitter at @Lisa-Rotenstein on Twitter and then Soul link to my LinkedIn page.

Outstanding. Will do that for you Dr. Rotenstein. So thankful that you spent some time with us today and super excited to stay in touch.

Thanks so much I hope you have a wonderful afternoon.Thanks for tuning in to the outcomes rocket podcast if you want the show notes, inspiration, transcripts and everything that we talked about on this episode. Just go to outcomesrocket.health. And again don't forget to check out the amazing healthcare Thinkathon where we can get together took form the blueprint for the future of healthcare. You can find more information on that and how to get involved in our theme which is "implementation is innovation". Just go to outcomesrocket.health/conference that's outcomesrocket.health/conference. Be one of the 200 that will participate. Looking forward to seeing you there.

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Recommended Book and Podcast:

An American Sickness: How Healthcare Became Big Business and How You Can Take It Back

RoS Podcast - Harvard Center for Primary Care

Best Way to Contact Lisa:

LinkedIn:  Lisa Rotenstein

Twitter:  @Lisa-Rotenstein

Mentioned Link/s:

CareZooming.com

Episode Sponsor: