Medicine, We’re Still Practicing Ep 01 Transcript
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Bill Curtis: Doctors, we put our lives in their hands. But how advanced is medicine really and how much is still guesswork? This is an honest and authoritative medical podcast. It's an intimate discussion that we call. We're Still Practicing. I'm Bill Curtis. We're here with two of the most respected doctors in the country. They'll help us make good decisions. Dr. Steven Taback is board certified in internal medicine, pulmonary disease and critical care. He owns and operates Consultants for Lung Diseases Medical Group. He's the clinical instructor of internal medicine and pulmonary disease. And he's also the medical director of intensive care at Providence Saint Joseph's Medical Center in Burbank, California. And most importantly, he's my very best friend. I'm honored to turn it over to our host, Dr. Steven Taback.
Dr. Steven Taback: Thank you, Bill. I'm honored to be here. Welcome, everybody, and thank you for tuning in. This is Medicine, We're still Practicing. And I'm your host Dr. Steven Taback. Medicine really is an art. If you look at artists, you look at painters, you look at sculptors, what they do is they develop subtlety over years of pursuing perfection of their art. And the same is true for the medical doctor. The more you practice, the more you pursue perfection, the greater your outcomes. So consequently, this is medicine and we are still practicing and we will continue to do so. Nowhere in the art of medicine better exemplifies the art itself than the field of plastic surgery. With us today is a world renowned reconstructive and plastic surgeon, Dr. Peter Grossman. Dr. Grossman is the medical director of the Grossman Burn Centers, which exist all across the United States. And he travels the world sharing his life saving techniques on the treatment of critically injured burn victims. What many people don't know is that he applies his reconstructive talents to those less physically challenged by beautifying the human form and elevating the self-esteem of thousands of patients to seek his artistic skills in pursuit of cosmetic surgery. Dr. Grossman, welcome and thank you for joining us.
Dr. Peter Grossman: Thank you, Steve. It's a pleasure to be here with you today.
Dr. Steven Taback: So tell me, what is your passion in your fields of both burn and plastic surgery?
Dr. Peter Grossman: You know, I'm very lucky in that I enjoy what I do. I will say that my passion as a burn surgeon is to be able to deliver something to patients that not every other physician can do. And it's a challenging field because you're dealing with patients and family members who are going through such emotional turmoil and physical pain. And to be in the middle of that, to be able to navigate them through this very terrible period in their lives and do it in a way that can be not just successful for them through the immediate hospitalization, but through their follow up and have a role in their lives for a period of time, gives me a sense of significance that I can positively affect people. And I'm proud to be a part of that team of people who do that.
Bill Curtis: You know, Peter, I want to tell you a quick story. I want you to picture a family in an airport food court pushing along a tray of about a half a dozen large boiling hot coffees. When their beautiful little 2 year old girl reaches up to the tray because she wants to play and pulls down these hot coffees all over her that girl and her mom live in the Grossman Burn Center for about two weeks, have skin grafts, have a variety of procedures. And I wanted you to know that that girl is Chelsea, who's our photographer today, who is my daughter. And I absolutely love you and your dad for allowing her to look stunning today as she looks. Thank you.
Dr. Peter Grossman: Wow. That's you know, I have to take a second because it makes me feel very emotional to to hear that. I was totally surprised to hear that. It's interesting when I met Chelsea today I go, you look familiar, but not from where she was two years old. But she's obviously a very beautiful, talented woman. And to have had any small part in making her continue to be a part of your wonderful family and that that's really is what healthcare and medicine is about. So thank you.
Bill Curtis: Your family has done important stuff for all of us for some time. And we appreciate it.
Dr. Peter Grossman: Very few people can imagine the trauma that someone has to go through when they're severely burned. There are very few things that are as painful to go through physically, as painful to go through emotionally, because what you think about when you're going through this process is how am I going to get through this? How am I going to look, how am I going to eat? How am I going to be perceived by my family, by my friends, by my co-workers? It's not only a physical trauma, but an emotional trauma as well. The bottom line is we all want to feel accepted in society and we all want to feel normal. And whether we like it or not, there is a sense of social ostracism from someone who looks different because of a disfigurement. So for our team and for me in particular, it's how can we utilize our tools that we learn in our education, in medicine, to try to get people to reach their optimal outcomes and to do that? It's a team approach. It's to try to use our medical doctors, our intensivists and our surgeons. And as a surgeon and particularly as a plastic surgeon, my goal is to try to make sure the patients can stay with me long enough so that I can get them to feel good about themselves. And that's where the bridge is from burn reconstruction to aesthetic surgery. Ultimately, aesthetic surgery is about making people look as good as possible because they want to feel good about themselves. You can say this is a sense of vanity, but in reality, all of us want to feel good and we want to look good and make ourselves feel happy. And I find very little differentiation between my burn patients who want to achieve that and my cosmetic patients who want to achieve it.
Dr. Steven Taback: So let's talk about the dichotomy of what you do, because most cosmetic surgeons out there, I hate to say this, but it's known as a big money field and obviously beautifying the human form and raising self-esteem, which is very important part, I think, of what you do, the psychological aspects, especially in our materialistic maybe semi-superficial world. Certainly one can see the benefit and the attributes of what you do, but very few plastic reconstructive surgeons devote so much of their time to burn work. If you had to choose, is there one side you like better than the other, or is it just that this well rounds you and you wouldn't give up either one for anything?
Dr. Peter Grossman: You know, it's a very good question. There is something really cool about getting your hands on somebody and having a positive effect on them. And that's why I went into surgery to begin with. And I like doing that from an aesthetic standpoint and I like doing that from a reconstructive standpoint. But in the field of cosmetic medicine and cosmetic surgery, the field is saturated. There are plastic surgeons. There are faux plastic surgeons. There are dermatologists. There are facial dentists. There are gynecologists who are doing cosmetic surgery. It's very hard to stand out. If I had to be honest with you from an ego standpoint, I feel I stand out from a burn reconstructive standpoint because it's an area that not many people want to go into. It's an area that's relatively limited. And I feel that I have more significance in this world because I can do burn surgery. So if I look at the whole picture, I probably like burns better because of that, not because I don't enjoy doing cosmetic surgery. I just feel a little bit more significant with burns.
Dr. Steven Taback: As an intensivist I certainly understand. I went into the field because the concept of being in the position where you could potentially have such a major impact and save lives makes you feel like you were pursuing the ultimate goal that doctors were were set out to do, and that is to intervene and try to save a life.
Dr. Peter Grossman: Yeah, I totally agree. I mean, I'm so in awe of people like you in critical care who can really take somebody really from leaving this world and bring them back, And how powerful an effect that has on family members. That is really what all of us start out going into health care for. And sometimes the economics sidetracks us. And I'm not saying that's bad or good, but the bottom line is when we go into health care, we won't go into medicine. We want to help people. And when you can really help somebody and help their families and and save lives, it's a pretty awesome experience,.
Dr. Steven Taback: But also very humbling experience, though, right.
Dr. Peter Grossman: Very humbling. I think you find out what you don't know. And I think that that's a very good point, is that for every person that we bring back or we have a significant positive outcome for, I think all of us in our head play that scene over and over again when we didn't do as good a job as we had hoped to do. Perhaps there is no way in which we could have. But if you're a really good character in medicine, you're always thinking of how you could have done better. And that plays a role in your head over and over again. And I think to a certain extent motivates us to continue to be better and better physicians.
Dr. Steven Taback: Yeah, definitely. I agree with you.
Bill Curtis: So, Steve, just for a second. What's the difference between what you do in the in the triage and critical care moment and in your ICU that is different than a robot will do sometime in the near future?
Dr. Steven Taback: Well, it's an interesting question, because, I mean, if artificial intelligence could get good enough, it's possible they could supplant human beings. But I was thinking about this actually on my drive over here today. And that is, there is a certain subtlety that goes along with the..., two things. There's a certain subtlety that goes into amalgamating all the information that you're getting, based on the science, based on what you've learned and what you've read, and formulating that into a likelihood that your diagnosis is correct and taking it in the context of the patient's background, the patient's medical history, the patient's wishes.
Bill Curtis: Well, isn't it more likely that a IBM Watson will get those calculations more correct than a doctor?
Dr. Steven Taback: It's interesting question because I was thinking that exactly. And so let's say somebody comes in and they're critically ill and they have a lung abscess. They've been smoking most of their lives. They're at the age where they're at high risk of cancer. Statistically speaking, this lesion in their lung that we're seeing on CAT scan is most likely a cancer. But if you take it in the context of the fact that the patient is having a fever, the fact that they're hypotensive, consistent with something that we deal with on a regular basis called septic shock, and knowing that maybe the patient has poor dental hygiene, which lends itself to long abscesses. I think the human element can look at this and pull it together and realize that people with bad teeth, people might have an alcohol problem. They may be aspirating. And this lends itself to an abscess, whereas the computer might kick this out that this is a tumor that you need to remove. When in reality what you need are antibiotics and some time, you don't need to be aggressive. So there are times when the machines may not understand what we understand as humans.
Bill Curtis: So it's still art more than science.
Dr. Steven Taback: It's, I think its a combination.
Bill Curtis: At least as much art as it is science.
Dr. Steven Taback: I think it is has much art as it is science. You can't you can't ignore either one of those sides.
Dr. Peter Grossman: I think that there's going to be a combination of art and science and a sense of humanity that the machines are going to take a little bit more time to be able to acquire. I'm a big believer that A.I. ultimately will have a overall positive effect on health care and will make better decisions in almost all aspects. But the one thing that A.I. may not be able to do, and I think Steve was alluding to, is how do they relate to the family? If you have someone who is going to die, how do you tell that family? How does A.I. tell that family? There is a an art.
Bill Curtis: Wait a minute. You're saying that doctors have good bedside manner?
Dr. Peter Grossman: Well, our hope is that we develop that.
Bill Curtis: Or just better bedside manner than the robot.
Dr. Steven Taback: And sometimes yes. Sometimes no.
Dr. Peter Grossman: But I think that the bedside manner is actually something that. Certain positions, I mean, are excellent at. And really is a skill that all physicians should learn how to do, because we all are our basic common denominators that we all care for family and we all love the people who are dear to us. And losing them is something incredibly painful.
Dr. Steven Taback: And we're all human and we have empathy so we can easily put ourselves or a family member in that position. A lot of times when you're training younger people, you'll say, if this was your grandmother, is this if this was your father, would you do this? Is this what she would do? Is this how you would say it? And as long as you can put yourself or your family in that position, you're always on track. An artificial intelligence device,they don't have a soul. They don't have a feeling. And that's the human element that I agree with you that that you cannot duplicate.
Bill Curtis: So how do you how do you handle that moment in critical care when you actually have to decide whether or not someone to going to make it?
Dr. Steven Taback: It's interesting question. The issue isn't, first of all there's experience. And that can tell you, based on this particular illness, having been in this position for several times, you know the trajectory. You get a sense of what the trajectory is. More often than not, it's not so much that you're telling the family that they're not going to make it because that that actually is kind of black and white. When you have something so catastrophic, in some ways, it makes it easier to proclaim. And if you can proclaim that the family can digest it, the more difficult element is when you have somebody that is so critically ill that multiple organs have failed. And you know statistically their chances of surviving are very low. And now the more difficult discussion that you have to have with family and to me, always the crux of that decision is you have to present it in the light that if your loved one was here, talking to us, able to understand what they were going through, what would your loved one want? In other words, we're gonna say that your loved one has multiple organs that are failing. There is a good chance they're not going to survive, but I can't guarantee that they're not going to survive. If your loved one was here, could understand that this is what was going on, Would they want to keep fighting? The question is, are the burdens of fighting, do they outweigh the benefits that you're gonna derive from that? And every patient needs to make that decision for themselves. I've had some patients who automatically would say I've had a good life. Let me go. Other patients say, no, you know what? My father lived 108 and I was doing fine up until this time, Doc.. I want to keep going. And many times and ,usually, the patient can't speak for him or herself because they're so sick. And that's the trauma, is that you have to present it to the family and you tell the family, I need you to tell me not what you would want because nobody wants to say goodbye to mom or dad. You have to tell me what your father would want or your mother would want that's in the bed as they can't articulate what they want. I need you to be the surrogate for them and tell me what they would want. Because you know them better than I.
Bill Curtis: And Peter, do you find yourself in that role?
Dr. Peter Grossman: I do quite often. And by the way, I think what you just said, Steve, is very..
Bill Curtis: Pretty profound.
Dr. Steven Taback: Profound and something that actually I want to take away for me, from you at this setting. Oftentimes we'll have somebody who is statistically at a point where their survival is going to be very limited, if someone is burned at 80 or 90 percent of their total body surface area. And if they're young, they may survive for a prolonged period of time because their heart is healthy. But ultimately, the sequelae or consequences of the burn injury lead to multi-system organ failure and infection. And we know that statistically they probably won't survive. So there's lots of resources and unfortunately lots of pain inflicted in my profession and taking patients to the O.R. and basically skinning them to get rid of the unhealthy tissue that puts them through enormous trauma that you'd rather not do if you know that statistically they can't survive. So you have to talk to family members and see where they're at and what does the individual who is injured, what did they want? But it's very hard for family members because there's a part of their own personal feelings of loss that they sometimes put ahead of the individual who's going through the pain and suffering.
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Bill Curtis: We're going to bring up insurance a few times during this show. Can you tell us a little about ,at what point does it become a battle between you and insurance? Will anything be covered that you decide to do to try to save someone or does insurance play a role in the care you might give a patient?
Dr. Peter Grossman: There is a difference between acute burn care and reconstructive burn care. An acute burn injury is something that happens right then when somebody is first initially burned, when their skin is going through a transition, when their body is going through a transition. And the effects of the burn injury are affecting them immediately as opposed to the long term effects of scarring and disfigurement and dysfunction. For anybody who is initially burned, they're going to be able to go to an emergency department and if decided upon by the person evaluating them, sent to a higher level of care, to a burn center. When they go to a burn center, they are going to have the same level of care, whether they have zero insurance, state or federal insurance or private insurance, whatever we might think about our health care system today in the United States, everybody does have access. We may not have choice of where we go, but we have access. When I take care of someone who is burned, we're going to take care of them as aggressively as we would any individual, regardless of care. That's not the same as once they leave the hospital and need their follow up care. And that is somewhat difficult to deal with because we're always fighting with insurance companies and trying to explain why this would ultimately be in the patient's best interest. In my field of.
Bill Curtis: Is the insurance company interested in that?
Dr. Peter Grossman: My experience with insurance companies is that they first and foremost are a business and their initial concern is how they can maximize revenue and decrease costs. That doesn't mean that they're without a soul. That doesn't mean that they don't ultimately think that it is their responsibility to do well for patients. But it may not be the number one priority despite what they may say in their advertising.
Dr. Steven Taback: One of my missions and I'm not a very political person yet, but I think I'm slowly becoming this way. But every CAT scan I order from my office, from the pulmonary practice where I'm taking care of patients with emphysema or a lung cancer, every CAT scan I order gets denied by the insurance, be that Medicare, be that private indemnity insurance. But the purpose for the denial is to force me to undergo a peer to peer discussion to justify the test that I'm ordering. Consequently, I have to get on the phone. I'm invariably put on hold for 10 minutes. I speak to somebody who finds out why I'm on hold and what I'm trying to do. I'm put on hold for another five to 10 minutes so that I can speak to somebody who is considered, quote unquote, my peer. And I have to state my case and claim as to why I want this CAT scan on this individual who has a large mass in their lung. Now, in days gone by, you could just order this test. What is the purpose of the peer to peer is that most doctors don't have time to get on the phone. And so if 10 percent of the doctors say, you know what, I don't have the time to do this. And in the process of waiting, another 10 percent of the patients say, you know what, I'm tired of waiting for this. Let's just not do it, doc. I'm done with it. I don't care. 20 percent of the patients then maybe don't even get the CAT scan. Saves the insurance company probably close to a billion dollars a year just by placing this impediment to ordering the scan. So to me, their main motivation is money and how can we pretend that we're delivering health care but in reality, optimize our our bottom line. And if some people possibly die in the process, so be it. I mean, that's the impression I'm getting from.
Bill Curtis: Are you talking about all insurances, Steve, because I'm here to be the listeners advocate. So are you talking about Medicare or are you talking about Aetna, Blue Cross, Blue Shield? Who are you referring to?
Dr. Steven Taback: I'm referring to everybody across the board. And yet within each of those organizations, sometimes you get reviewers that are very understanding and realize the gravity of the situation and the veracity of what you're asking for and automatically realize that this is something that needs to happen. But I have not encountered one insurance company thus far who has not had a denial process,who forces you to go to a peer to peer. If there is one out there, I stand corrected. Feel free to contact me. I'm happy to correct this, but I have dealt with the Blues, the Aetna's, Medicare, and I have received denials in spite of the fact that they have been given an adequate history to justify the examination. And in literally ninety nine percent of the time when I discuss it with a reviewer, it's approved. It's a process, I believe, in my opinion, meant to be an impediment to ordering the test so that next time you may think twice about the fact that if I ordered this CAT scan, I'm now going to have to be on the phone for 20 minutes. Is it really worth my time?
Bill Curtis: So we basically have the right to health care, health insurance, unless our insurance company can process their way out of it.
Dr. Steven Taback: Absolutely. That's exactly what's going on in this country. You have the right and on one hand, you have the moral edict. And now business, big business has to decide how to get around that surreptitiously so that it's not done overtly. Because overtly everyone would be yelling and screaming. This is something I'm sure the general public does not know about. And hopefully now somebody will know about it and eventually it'll work its way through the legislative process.
Bill Curtis: Peter, do you run into this as well?
Dr. Peter Grossman: I do. And I wish I could disagree with you, Steve. But no, you're you're right. So when we're talking about acute burns, we're going to take care of them. They're going to be admitted. And their insurance, if they have insurance, are going to cover them somewhat. But the hospitals are going to have to argue that their treatment plan was the correct treatment plan. And oftentimes they will only get paid a portion of the costs that that was put out. And what happens is that they have to go through the argument. The providers, the physicians have to go through an argument that what they provided for was reasonable. Now there's a certain amount of merit in having to justify what you did. But unfortunately, I think that the message that comes across is that we're going to modify the best potential procedures for patient or the best potential care to fit into the mold that the insurance companies want to be able to pay. And that is somewhat problematic for the consumer, because the consumer feels that when they have paid a lot of money for insurance, that they are covered, that everything that they're going to want to do, whether it's during your initial hospitalization or their subsequent need for further care, is going to be covered by the insurance company. And it often isn't. And what's more noticeable to the patients is more and more physicians not being in network, not accepting the insurance. And that's frustrating for patients because they can't understand why if they're paying for a certain amount of insurance, why they're not being covered by their physicians. What they don't always understand is that the physicians aren't really being compensated. And oftentimes they actually lose money on subsequent follow up. So it's a problem. I'm not sure what the real answer is. I'm certainly not advocating a a one party system for care because I think that will disincentivize people for doing more and more to try to advance health care in this society. But I do think that there has to be some explanation from insurance companies to explain why they're not covering.
Dr. Steven Taback: Let me give you an example, actually, of a denial that we just received. We had a gentleman who had known history of thyroid cancer, had the thyroid cancer removed. And as a follow up, I had ordered a PET scan because a PET scan is a relatively new technology , I say that its been around for the past, maybe, you know, a decade, because time goes by so fast for me. But we'd recommended a PET scan and the reviewer said, no, this patient really needs a thyroid scan. If it was thyroid cancer, before you move on to the next level, I want you to do a thyroid scan, which I had no problem doing. I said, you know what, that's actually probably a good idea and the thyroid scan showed something suspicious. But now the radiologist and myself are both recommending a PET scan. The insurance companies said, well, we've reviewed it and we believe a PET scan is experimental and we deny it. So here I've been asking for this PET scan now for three months. We did a thyroid scan instead. We have a radiologist now who is advising the PET scan. The insurance company is still denying it. We are going to fight it and we're going to take it under appeal. But can you imagine having cancer, having something suspicious? And now, because of this ridiculous process, it's going to take six months to get a scan that hopefully is not going to come back showing something very serious for this patient that could have been addressed six months before.
Bill Curtis: Is the patient aware of this?
Dr. Steven Taback: Yes. Absolutely. Know every time.
Bill Curtis: What is our listener do about this?
Dr. Steven Taback: Well, on multiple levels, on the local level, you know, immediately, probably if you are the one caught in this process, you probably should find a way to pay out of pocket. You can negotiate sometimes with freestanding radiology companies. You can negotiate a cash price just so that you can get what you need. So because you don't want to delay your care just out of spite and just because morally it's the wrong thing to force yourself to pay. So this is what the insurance company probably wants you to do is for you to pay out of pocket and you probably should. But beyond that, you should pursue the appeal process with your HMO, with your insurance company, for sure. You need to make it as painful for them as they're making it is for us to actually deal with us. They should probably get an attorney immediately on board, if they can, to write a nasty letter. Sometimes just a little squeak in that wheel will get the process going. And there's one more thing, globally, they should be talking to their legislature. This is the time when you do want to write your proverbial congressman or congresswoman and say this needs to change because the people in politics, those those few people in politics who truly have a heart, who are truly looking to make a change, they probably don't know that this is what's going on.
Announcer: On the next episode of Medicine, We're Still Practicing, Dr. Steven Tsback, Bill Curtis and Dr. Peter Grossman continue their discussion about health care, the cost of medicine and cosmetic plastic surgery.
Dr. Peter Grossman: We need to embrace age, not aging. Age is inevitable. Age brings with it experience. Aging is a process of failure of our systems.
Announcer: See you next time. And take care of yourself.
Announcer: This episode of Medicine, We're Still Practicing was hosted by Dr. Stephen Taback and Bill Curtis, produced by Chris Porter, Sound Engineering by Michael Kennedy. Theme Song by Eric Dick, recorded at Curtco's Malibu Podcast Studios. Additional Music by Chris Porter. Today's guest was Dr. Peter Grossman. Be sure to subscribe ,write and leave a review wherever you get your podcasts. Thanks for listening.
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