• Visit Primary Care Collaborative, Jamaica Hospital, and connect on LinkedIn.

Joe Sanok 00:00:00  It's time to build insurance. Did your heart just sink? Practice solutions connects mental health providers with quality insurance Billers who manage your billing process, allowing you to spend more time working with your patients. Their Billers are all in the United States with specialized experience in billing for mental health. With practice solutions on your team, you can confidently accept insurance patients knowing that you've got an expert managing claim submission, follow up eligibility and benefit checks, payment posting and denials. Need help collecting from your patients? Practice solutions has you covered there too. Whether you are collecting insurance, copays and deductibles or private pay, they have solutions for both. Practice solutions is offering practice to the Practice podcast listeners, a free consultation and 15% off the first three months of billing. Head on over to practice. That's practice. To schedule a Consultation to find out which service is right for you and leave your billing worries behind. This is the practice of The Practice podcast with Joe Santos, session number 1208. I'm Joe and I'm your host.

Joe Sanok 00:01:25  And welcome to the practice of the Practice Podcast, where we help you build a thriving private practice that you absolutely love. You know, we want both sides, that we want you to thrive. We want you to do well, but we want you to love it. We want you to feel aligned with the kind of work you're doing. We cover big picture social issues on this podcast. We talk about the industry. We talk with people outside of the counseling world quite a bit. And today is going to be one of those days where we dig into kind of the whole medical establishment, which is actually really exciting for me. as many of you know, I've been through all sorts of medical types of things. I was diagnosed with type one diabetes in my early 30s. Had thyroid cancer, you know, two years ago. I came home from Mexico with salmonella, and that's been a two year. Just. I've had emergency surgeries and flare ups all from this salmonella. and, you know, there's lots of times that I kind of say to myself, the system doesn't seem to be working.

Joe Sanok 00:02:24  you know, my mom's a nurse practitioner. my sister's a nurse. my brother in law, he's a, ophthalmologist. And so it's like when one of us goes in the hospital, we have a lot of medical knowledge, and oftentimes we catch these things that happen, where it's like, this should not have been. This should not have happened. So I'm really excited to dig into kind of the medical system, some of the history today. really excited to have Doctor Allen Roth, who's a D.O., a physician practicing family medicine and palliative care in New York. He is chairman of the Medici Health Network Department of Family Medicine and Ambulatory Care. He is the recipient of numerous awards, including New York Magazine, Best Doctor, and was featured in time magazine as a Guardian of Health Care during the Covid 19 pandemic. He's a professor of family medicine at Knights College of Osteopathic Medicine, and an assistant professor of social and family medicine at Albert Einstein College of Medicine. His new book, A Return to Healing Flexner, Osler, and How American Medicine Went Astray.

Joe Sanok 00:03:31  He's co-written with Doctor Andy Lazarus. Welcome to the practice of the Practice podcast. Alan.

Dr. Alan Roth 00:03:38  Thank you, and thanks for inviting me to join.

Joe Sanok 00:03:41  Yeah, absolutely. Well, I know we were supposed to have Andy here with us and we had some tech issues. So you were speaking on behalf of the two of you? really excited to dig into this. I wonder, before we talk about the book and talk about, you know, what happened during Covid 19. That time magazine noticed you. we'll get into all that. why'd you go into medicine?

Dr. Alan Roth 00:04:01  If you really want to know, I have to be honest. I'm the youngest of three boys of Jewish heritage, and my mother always needed to say. My son, the doctor. I was the last one. None of my brothers did it. And, I did it for my mom, who is the most influential person in my life at the time. my wife is now, thank goodness. but, she she unfortunately passed away like, a month after I graduated from medical school.

Joe Sanok 00:04:30  but she.

Dr. Alan Roth 00:04:31  Did.

Joe Sanok 00:04:31  It for a month.

Dr. Alan Roth 00:04:32  She got to see it.

Joe Sanok 00:04:33  So what did your other brothers get to do? since they didn't take that up.

Dr. Alan Roth 00:04:38  So, my, my little brother is, a physician's assistant, and my oldest brother is in computers and marketing and things like that.

Joe Sanok 00:04:51  I was kind of hoping you'd say, like they. One's an artist and one's like a traveling musician, and then you just had to be the doctor. But very practical jobs the other two got to.

Dr. Alan Roth 00:04:59  Yeah, yeah. Pretty practical.

Joe Sanok 00:05:01  Yeah. Well, Alan, so I want to talk about let's go back to Covid 19. You know, at the time of this recording, that kicked off about five years ago. and, you know, time magazine listed you as a guardian of health care when you think about that pandemic. what was your role? What did that look like? during that time for you?

Dr. Alan Roth 00:05:22  So pretty much by far and away the worst time of my life. Queens County in New York, was the epicenter of the Covid pandemic.

Dr. Alan Roth 00:05:32  My hospital in particular. We got one of the first cases in the nation, and, we're a safety net hospital. We care for underserved patients from about 50% of the population in Queens or immigrants, about 400,000 undocumented folks, living in close quarters and apartments. And the borough simply got overwhelmed in a matter of a week or two. Our E.R. got flooded. We called it the petri dish because, you know, people just. If you came in not infected, you left infected. And it was just such a high rate of death. families weren't able to come to the hospital to visit their loved ones. We had to do it on iPads. And, you know, literally family, patients and families couldn't say goodbye to each other. And, it was horrific. I still have PTSD for it. I've had Covid six times. I have what's called long Covid, which consists of brain fog, body pain and fatigue. you might notice it sometimes when I speak after pause for a second. You know, I never had to do that.

Dr. Alan Roth 00:06:41  Like, what's the next word that's coming out? It was horrendous. to live in healthcare in New York, during that pandemic. Wow. I'm traumatized.

Joe Sanok 00:06:51  Yeah, well, I'm not going to ask you to dig into too much more of that. But thank you for for what you did for New York and for the United States and for the globe, in slowing, that pandemic. I want to spend most of our time today kind of talking about concepts from your book, because I think it's a really important discussion, especially now with what's going on in the world. You know, the book A Return to Healing Flexner, Osler, and How American Medicine Went Astray. you know, one of the things you cover in there is really American medicine in the history. take us through some of the highlights and lowlights of the history of medicine in America.

Dr. Alan Roth 00:07:29  So I don't think there's a lot of highlights, except for we have amazing technology. And if you have a heart attack or a stroke, we could save your life.

Dr. Alan Roth 00:07:40  but we concentrate on that as opposed to preventing heart attacks and strokes. So the book goes back, a hundred years or so to Johns Hopkins, where there was a change and a debate over how medical education should go. And literally the fight was Sir William Osler, who is an idol of mine, and Andys. It's actually how we met. We both heard each other quote Osler in in our lectures and we said, oh my God, there's another person out there. And he was the physician's physician who believed in the art of medicine. He was a scientist. But Hopkins brought in a German educator named Flexner, hence the name of the book, who totally changed the health care education system to one that was essentially totally based on science. And unfortunately, the science is not exact and didn't feel that the art of medicine touching a patient, speaking to a patient, being with a patient made a difference. And Osler knew it made a difference because it's the patient that tells you what's wrong with them. And that's a bit of a quote from him.

Dr. Alan Roth 00:08:56  And and Flexner won. And we've created a system that still exists today of, you know, four years of undergraduate medical education that really have nothing to do with you being a doctor and four years of medical school, most of which have nothing to do with being a real doctor. And and then you go practice your art clinically and you don't start doing that into, you know, 12 years later. It's just a dysfunctional mess. And we are training a bunch of, test takers and clickers that I call them. You know, I teach in a residency. The residents take out their phone, they put in numbers on every patient they see. They spit something out. And this is what the patient in the room like. It's often the patient is extraneous to what's going on in the actual health care.

Joe Sanok 00:09:45  Yeah. And it's it it's data and data out oftentimes. and I mean, when I see my endocrinologist for my diabetes, he, he laments it, but he's like, I have to basically look at this computer while I talk to you, to get all the information in or we won't get paid.

Joe Sanok 00:10:01  And I know it's not good, but, that's what I have to do. you know, how did it go from, you know, I think of kind of the romantic, you know, traveling doctor that stops in different towns. And maybe that's not even true. and then, like, kind of a small town doctor to this just huge system that we have now. I mean, like, what's some of the history there?

Dr. Alan Roth 00:10:25  So it's the education system that we created. We created a system based on numbers and not people. And we've created what I call the over specialization of healthcare. The vast majority of the world, about half the providers of medical care are the doctor. You talked about a primary care physician who took care of all the patients, the generalists taking care of the patients physical needs, emotional needs, spiritual needs. They knew their patients. They know their family. That's my practice. I have patients for 38 years now. You know, call me on my cell phone. We know each other well.

Dr. Alan Roth 00:11:03  They know who I am. And and that's gone away. You know, in our country, the vast majority of physicians now become specialists, this second level specialist. So in neurology, there's a neurologist and then there's a neuro seizure doctor and a neuro brain tumor doctor and a neuro list, and there's no relationships. And to me, the art of medicine is about relationship based care. It's not a transaction, okay? It's about a relationship. And what makes relationships in medicine and in mental health, which, you know, probably 50% of my work is anxiety and depression because patients with chronic complex illness have anxiety and depression, and we deviate from that, that those things don't matter. It's you know, what is your a onesie. So a onesie is the diabetes level of control, as you know. And that's the most important grade that an endocrinologist has. Because if he doesn't get your A1 c down or I don't get your A1 c down, I get dinged by the insurance company, but I get dinged even more by the insurance company because I take care of poor, underserved patients who don't have the means for healthy food, often don't have the means to get medications that they need, especially the newer fancy medications that are out there and are stuck on some of the cheaper, older drugs that don't promote long life.

Dr. Alan Roth 00:12:32  They don't have access to exercise and lifestyle changes and good nutrition. So I am actually dying because I take care of poor people. There's no compensation system for that because it's about the number. So Ugo is a person. Have feelings and emotions and having a good relationship with your doctor to motivate you to eat healthy and exercise. Like that's huge. And you know, I motivate my patients. I have many of my diabetics do really well who have the means to do really well. But it's not about a number of an agency. It's about a human being. You're a human being and you're not in a onesie or a micro albumin in your urine, which means you're having diabetic kidney disease. Or did you have your diabetic eye exam? So that's what we get tested on. Diabetic kidney function. Diabetic urine. Diabetic eye diabetic feet a onesie. It's not about Joe. It's it's it's a ridiculous system.

Joe Sanok 00:13:29  How do we get out of this?

Dr. Alan Roth 00:13:31  So I do think there's a way out the mindset. There needs to be a huge shift in mindset.

Dr. Alan Roth 00:13:38  The shift in mindset needs to be one that involves goes from a reactive system of healthcare to more of a preventive system of health care. Okay. We need to. We need to be smarter in how we treat people. In truth, I don't think we have a health care system. We have a sick care system. We take care of sick people. Like I said, you have a heart attack. You have a stroke, you get shot. We will save your life. Better than any other country in the world. But we do nothing to prevent heart attacks and prevent strokes, and to prevent mental illness and substance abuse and alcohol abuse. We just have such high rates of dysfunction in this country because it doesn't pay well to prevent it pays well to treat. So a cardiac interventionist who gets, you know, $10,000 for a stenting procedure is a very happy camper. The same thing with the neuro interventionist or the orthopedic surgeon or the cosmetic surgeon? Dermatologist. That's where the money is. There is no money in primary care, mental health, wellness and prevention.

Dr. Alan Roth 00:14:45  And that's the way we kind of need to go. We're a system that it's not about you. It's about doing a test. Okay. We do a test so we can make a diagnosis so we can treat you and do things to you. It's not about.

Joe Sanok 00:15:01  A lawsuit that you.

Dr. Alan Roth 00:15:02  Didn't, and you're 100% right. So when your doctor talks about the documentation he needs to do, one is to send out a bill. And two is to prevent a lawsuit. And and, you know, as a family doc, like, I don't make the millions of dollars. I'm not poor, but my malpractice insurance is $35,000 a year. I make an average of about $60 a patient. I have to see a lot of patients just to pay my malpractice insurance, and I'm not doing it so I could cheat numbers. I spend time with my patients and and this just clicking thing of test, test, test, you know, diagnose leads to this conundrum that I call over testing, leading to overdiagnosis, which leads to overtreatment and many complications and morbidity and mortality associated with horrible outcomes.

Dr. Alan Roth 00:15:53  We spend $4 trillion on health care in this country, which, and we spend at least twice as much as every other industrialized nation on health care. And we rank like number 47 in longevity. We're ranked as the most ineffective, inefficient, most expensive health care system in the world. We would understand if we were spending the trillions of dollars and everyone was living longer and better. But it's not true. And the vast majority of my patients are miserable with their health insurance. Okay. They're miserable going to a hospital and how they get treated, they're miserable having to be sent to 5 million specialists. The system is broken. We're a sick care system. it's just horrific.

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Dr. Alan Roth 00:18:04  So, you know, you would think we would take the best of all worlds. Okay. Of all countries and all places. But we don't.

Dr. Alan Roth 00:18:14  we know for sure that a system based on primary care and primary care includes family medicine, internal medicine, general pediatrics, women's health, and ob gyn, and mental health is part of that. We know that a strong infrastructure in that will prevent the problems that lead to the need for all the specialists that we have in this country. And we don't invest in primary care. So out of the health care dollar, only 5% of the money is spent on primary care. Our money is being spent on drugs and hospitals and the profits of insurance companies and, and a lot of rich doctors who were doing a lot of fancy procedures, making a lot of money. All we would need to do, and it's a simple shift, a shift to the base that focuses on primary care. Like I'm telling you, every human being should have a primary care physician, and all we need to do is maybe double the 5% to 10%. So literally we would be taking, you know, 1% away from some of the specialists.

Dr. Alan Roth 00:19:21  They wouldn't even notice the difference if we invested that in a primary care infrastructure, so that everyone had a primary care doctor with quick access to care, because there's just not enough there's shortage of primary care. People don't have access to care. Therefore they go to either an emergency room or urgent care. You go to urgent care with chest pain. They're either going to send you to the hospital or have you see a cardiologist. You know, if you go to urgent care with back pain, they're going to send you to a spine specialist who's going to do an MRI and X-rays and, you know, $50,000 later, you needed physical therapy and it won't cost anything. We just need to shift the money around because we're already spending way too much money on health care. It's 20% of the country's GDP. No other country is anywhere near that.

Joe Sanok 00:20:15  What do you think? Because our primary audience here are therapists. what's your therapists know about this system? unique to mental health.

Dr. Alan Roth 00:20:24  So I do a lot of work in mental health.

Dr. Alan Roth 00:20:27  I our hospital has inpatient psychiatric units, and I'm a medical consultant. Where I take care of their medical care. We don't have enough access. I tell all my patients, when I see patients, our system is broken. I know a lot of your folks are in private practice. There needs to be a system to better reimburse all health care providers for the thinking part of medicine, for the spiritual part of medicine, for the talking part of medicine. And that's not we're not paid that way. We're paid to do things to people with pay, to do a test or a procedure rather than talking to people. So in our health care system, if you're extremely poor and you have Medicaid, you know, we could get you appointment within a month or two. And if you're extremely rich, you could pay your therapist. You know, it's the folks in between whose insurance is, you know, will pay a therapist, you know, $35 for a visit. Okay. I know you guys can't make a living on $35 a visit.

Dr. Alan Roth 00:21:32  Just like I can't make a living with my malpractice on $70 for a visit. The system needs to change to pay. Health care professionals for their time, not for a procedure. And if that would change, our mental health system would improve greatly as well as our primary care system would improve greatly. But it's just not that way right now. So if you could afford it, there are great therapists out there, you know that. I know that, and I work with many of them. So my patients that have the means to pay a therapist what they truly deserve and earn, they get that. But, you know, the Medicaid rates for therapists, like no private therapists could, would take that because you couldn't afford it. You couldn't pay your bills that way. So the system is broken. We need we need to pay for mindful medicine as opposed to paying for procedures.

Joe Sanok 00:22:27  Now if we were to think about mindful medicine in the therapy room and also mindful medicine with folks that therapists are collaborating with, what would that look like if we shifted into more of that?

Dr. Alan Roth 00:22:38  So, I mean, I think so much of the medical problems in our patients is related to the stress in their life.

Dr. Alan Roth 00:22:47  Not sleeping. People don't eat well because they're stressed. People don't exercise because they're depressed. And mental health is a is a huge problem in our country that has not been addressed adequately except for rich folks that could afford, you know, a great private therapist. It's just it's not designed that way. It's not designed to pay for it. And I think, you know, I always say 50% of what I do is a therapist. Okay. I'm either treating someone with anxiety, depression, insomnia, purely, you know, mental health related diagnoses or the other half of the 50% I'm treating have anxiety and depression from their chronic, complex medical illnesses. Everyone with chronic, complex medical illness, you know, knows what the future holds for them. People who have heart attacks get depressed all the time. People get strokes and can't use, you know, their bodily functions or depressed and again, preventing mental health issues leading to chronic, complex illness. To me is essential. You know, I'm a huge believer in, you know, counseling and therapy.

Dr. Alan Roth 00:24:01  I rarely need to send my patients to a psychiatrist because I use therapists and I co-manage with them. And I have a handful that, you know, know me well. You know, we get permission to speak about our patients, and I'll get calls from my, my therapist all the time and say, you know, Allen, you know, I think Mrs. So-and-so really needs an antidepressant. Now we discuss the different medications or they really like, they're so anxious they need a little low dose of a benzo for a couple of months to get them through what they're going. So. Working hand in hand with providers is a way for I think we can improve the, you know. The mental health of our nation.

Joe Sanok 00:24:42  Yeah. Now, if you were in charge of, kind of the overall just returned to healing of the American medical system, what would be the top 3 or 5 things you'd change? You said that, you know, putting more into primary care. What else do you think needs to shift?

Dr. Alan Roth 00:24:58  So that is the biggest shift.

Dr. Alan Roth 00:25:00  You know, we need to invest in primary care is is is one of the biggest. We need to shift from a numbers game which which we call, you know, the science of medicine to the art of medicine. I'm a scientist. You know, when I don't know something. You know, we have great AI tools. Now, I could put in a couple of questions and get the answer. That part has become easy. But the art of medicine. You know, I could talk to a patient and till I'm blue in the in the face and head and the rest of my body and getting cold and dead. But if they're not going to listen because they're not in the frame of mind, knowing that they might not want to take this drug or that drug or that procedure, or they don't want to invest in their lifestyle of nutrition and exercise and mental health. So we need to shift to that mindset of prevention over treatment, prevention of chronic complex illness rather than treating it. We need to shift to a system about not asking the patient, what's the matter with you? Like that's what doctors essentially do.

Dr. Alan Roth 00:26:08  But what matters to you? What is important in your life with the conditions that you have, whether it's mental or physical? And how can we do a team approach us together as a team to make you better and prevent you from this downward spiral that so many patients now have in this country of obesity, obesity leading to diabetes in most patients. Not type one like you have, but obesity leading to type two diabetes and hyperlipidemia and hypertension, which then leads to heart attack, strokes and cancer. That is, 90% of what providers treat in this country is that complex group of things. People are dying from heart attacks, strokes and cancer, and we could prevent so much of it. So it needs to be a mind shift, you know, away from sick care to WellCare to the promotion of wellness and health and what truly matters to patients and their families.

Joe Sanok 00:27:06  Ellen, I always love asking people that are doing this sort of work what this looks like in your own life. Like what kind of habits do you have to return to healing for yourself?

Dr. Alan Roth 00:27:17  Sure.

Dr. Alan Roth 00:27:17  So I could tell you a little bit. You know, my life changed. You know, I have high blood pressure, I had diabetes, I was very obese at a time, and I, I read a book by a colleague of mine called Wayne Jones, and the name of the book was How Healing Works. and I read the book and it changed my life. It talked about the holistic, patient centered approach to health care and what we need to do to work with patients as partners to make them have healthy and well and happy. And how that was so important. he subsequently wrote a book called Healing and Cancer, looking specifically at cancer patients. And he actually named our book for us because, the the publisher didn't like our first title, which was uncared for. so the original name of the book was uncared for, and we had the Flexner and Osler in there, but they didn't like it. so I reached out to my friend Wayne. You know, I said how healing works.

Dr. Alan Roth 00:28:19  And and he came up with the title, you know, a Return to healing. And that's where we need to go. And that's what the book is about. It describes our dysfunctional system, how we got this dysfunctional system and how we get out of it. And it's really not hard. It's really common sense how to get out of it. And that's simply what we need to do.

Joe Sanok 00:28:41  So awesome. Ellen. The last question I always ask is if every private practitioner in the world were listening right now, what would you want them to know?

Dr. Alan Roth 00:28:49  I think every health care practitioner needs to fight for their patients. It's about patient first, and I think every health care practitioner, if they're truly concerned about their livelihood and their income and what they do, really needs to get involved with their organizations to promote appropriate payment models so you can make a living, appropriate patient numbers, a shift in all these metrics that we're all being evaluated on of. You know, I'm only a good doctor. If I could get your agency down, there needs to be that shift.

Dr. Alan Roth 00:29:24  And if the health care providers, whether you're physical medicine or mental health, are not advocating. I don't see it happening. I see the system continuing to to crumble. And, you know, I personally volunteer for an organization called Primary Care for All Americans because if if we all don't do something to make our system better, it's just going to keep getting taken over by the medical industrial complex of the big pharma and device makers and insurance companies and big hospital systems and and we're doomed. But it's a simple shift of mindset.

Joe Sanok 00:30:03  So awesome. Well, the book is a return to healing. Flexner, Osler, and How American Medicine Went Astray, co-written by Doctor Andy Lazarus and Doctor Allan Roth. If people want to connect with you more, are there any websites or other things we'd want to send you to them?

Dr. Alan Roth 00:30:18  Yeah, we turn to healing. Com.

Joe Sanok 00:30:21  Awesome. Thank you so much for being on the show today.

Dr. Alan Roth 00:30:23  Thank you for having me.

Joe Sanok 00:30:32  You know, when I think about taking what's in our head and putting it into a book, you know, when I wrote Thursday is the new Friday.

Joe Sanok 00:30:41  You know, it takes a lot of work to do a book. but it's such a great thing because it brings together, you know, a lot of these thoughts. so I want to just encourage you, you know, if you're seeing things in therapy, if you're seeing things in the world, just start to gather those thoughts. Put it on a Trello board. if you see news articles that kind of hook you a little differently. Drop that into a Trello board. keep track of those things. because I imagine a lot of you have books inside of you that are going to reshape the way we think about society. So I want to encourage you to just start gathering stuff. you know, if you're gathering things, that's a way that when you finally get to that point that you want to write a book, you've got a lot there that you can that you can draw from. It's not just a blank screen, it's all sorts of ideas. How do I organize all of these things and what do I keep in? What do I pull out? All those different things.

Joe Sanok 00:31:30  So also we couldn't do this show without our sponsors. Today's sponsor is Therapy Notes. Therapy notes is the best electronic health records out there. It helps with your billing. It helps with your automations, your scheduling, all of that. Head on over to Therapy Notes and use promo code Joe at checkout. They'll know that then their podcast dollars are working, but also they'll give you a couple months for free. Thank you so much for letting me into your ears and into your brain. Have a great day. I'll talk to you soon. Special thanks to the band. Silence is sexy for that intro music, and this podcast is designed to provide accurate and authoritative information in regard to the subject matter covered. It is given with the understanding that neither the host, the producers, the publishers or guests are rendering legal, accounting, clinical or other professional information. If you want a professional, you should find one.