Don't Blame the Canary

Welcome to season three of Derms on drugs, a video podcast brought to you by scholars in medicine, the best educational platform in dermatology and provided no cost to medical providers. Derms on drugs is for cutting edge dermis, dermis comedy, Dr. Matt Zyres and Doc's dermatology in each week. I'm Dr. Marzinski buddies, Dr. Laura Ferris from the University of North Carolina and Dr. Tim Patton from the University of Pittsburgh. And we use our 70 years of combined derm experience to discuss debate and dissect the hotest topics in dermatology. It's everything you need to know to be done. It can get you to the dermat and you actually have to put it listening. New episodes drop every Friday on scholars in medicine, have a podcast, modify another makeup podcast platforms. And I highly recommend that you download the scholars in medicine app to access the full podcast video archive and explore the best derm education of content out there. Real, pharma independent coverage of all of dermatology, supported by an amazing AI clinical consultant called Ask Simon. And today I could not be more excited. We have one of my favorites. Actually, I will say it's the only person in the world who I think is a more entertaining lecturer than I am, which was a very big blow to my ego the first time that I was at one of her lectures. We've got Dr. Lisa Swanson, a board certified pediatric dermatologist in the middle of nowhere. Iowa. I'm sure there's a name of the town. But I don't know. I don't know. I don't know. What am I saying? Yes, if it's in Idaho, it's the middle of nowhere. So I'm sure, but I'm sure we've got the potatoes. Iowa has the corn. Okay. I live in potato country. I have a corn country. Yeah. What do you know what it is that makes I Idaho the potato capital? Like is what is it about Idaho that the potatoes are so good? I think it's the temperatures and the soil. And you would not believe how cut throughout the potato farming industry as you guys. I want to create a series on Netflix, maybe like Taylor shared an ad about the cut-wrote world of potato farming because they all want the contracts for like to be the potato supplier of McDonald's and Chick-fil-A and in and out. And I even have a title picked out. Are you guys ready? Ready? Oh. Sput. Nice. Okay. That's good. That is pretty good. Is there any like potato sabotage that goes on? Yeah. Really? Yes. Yes. I mean, it's literally like a soap opera in the potato farming. Yes. You would think of potato farmers as being very down to earth people. I know, but they want to sell their potatoes. Yeah. Yeah. My grandfather always said money, money makes people act funny. Oh yeah. That was that was one of his lines. That was one of his lines. So all right. So for our listeners, we are having a very, we're going to have a very interesting. It's probably going to go in a different direction than what you're expecting. I'm about to say you're expecting some like peeds, derm, like wariantatopic, no, no, you don't get what you expect when you come to derms on drugs. We have Dr. Lisa Swanson on to talk about burnout. Yeah. And you might be you might be thinking to yourself, burnout, we're dermatology people. Like if there's anybody in the world who shouldn't get burned out, it is us. And if you believe that, what it means is that you don't really understand what burnout is about and that there's different types of burnout, different things that make you burn out. It's it's not about working 70 hour weeks and no sleep and whatever. We're going to get into really what it's about because I think it's something that a lot of people struggle with to some extent and just knowing that you're not alone and that a lot of us struggle with it, I think makes a big difference. So before we get into our first article, Dr. Swanson, how did you kind of get interested in burnout? Because it was, you know, you and I had like a little interaction and I was something to come out that day and I was like, oh, and you're like, oh, when I lecture about it and I was like, what? So how did you get interested in burnout? I got burned out. I got really burned out. And often when I'm doing my talks on burnout, I actually, I talk about like how do you know if you're burned out and there are like quizzes you can take, you know, like in like I remember all those teeny buffer magazines that I had when I was a teenager, like how can you tell that you're a good girlfriend, like you take this quiz or whatever. Like you still get them, you still get them. Sometimes, sometimes. And so there are these quizzes that I say, or if your Amazon shopping cart looks like this, because I actually took a screenshot of my Amazon shopping cart today, ordered seven books about burnout because I was like, how do I solve any problem being a doctor? I read about it. I educate myself. I kind of learn how to tackle it. And so I ordered and read seven books on burnout and was able to utilize them to kind of build the talk that I give about burnout. And so that's how I got into it. I got burned out. Okay. Fair. I get into it later for listeners, but I also have been a suffer of burnout. So but let's go ahead and get into our first article. There's been some really, really cool literature about this stuff lately. So Dr. Ferris, what do you got? Okay. What I have is actually something published really recently in JAMA Network Open. And it is moral distress and occupational burnout in US physicians. So they basically start the paper with talking about physician burnout. Why does it matter? It's important obviously because we want our physicians to be happy, but it also has like pretty real consequences because it is a big reason why physicians leave the workforce. And so we have a physician shortage and there's projections of what our physician workforce will look like. But that kind of assumes people will stay in the workforce. And if they don't and a burnout is driving them out, that's really important. So what they did was they basically wanted to survey people about burnout. And then they ask questions about moral distress and moral distress is basically putting in situations where you just feel like it's hard to know how to do the right thing or what the right thing is or knowing what the right thing is, but not being able to actually do the right thing. So yes. So there's a very specific because I get this wrong all the time. So I really looked it up before the thing before we did this today. When when I think of moral distress, I always start of moral dilemmas where like, oh, you're one of your children is going to die and you you only have enough food, you have met enough medicine to save one, which one are you going to save? Right. Like that's a moral dilemma where there's no right answer. That's when I always start moral distress was no moral distress is there's an obvious right answer. And the system is keeping you down. You know what the right answer is, but you can't do it. So it's not being empowered to do not having the power to do the right thing. The sort of way to think about that. All right. Yeah. So yeah. So in a lot of times what is our not having the power? It's basically bureaucratic brick walls. And what does that turn out to be in, you know, for us and medicine a lot of times that's actually insurance. So all right. So the the national survey was over 5,700 docs. There were 135 dermatologists, which was 2.4% of the sample. And broad spectrum. So about half of them were private practice about a third academic, some BA, and then other settings as well. So what did they find? Basically 39% of physicians report high moral distress. The average was 3.29 on a zero to 10 scale. And they then, you know, looked at the relationship between burnout. So it was relatively strong. So it was an R of 0.55 and de personalization of 0.5. So what does that mean? Moral distress does explain some, but not all of burnout. And roughly 30% and it's, you know, moral distress. They thought they kind of said is responsible for like a third of the variability and emotional exhaustion and a quarter of de personalization. So demographics important to look at women more likely than men to experience moral distress. I first you know why? 2.9. You know why? It's as I mean, you might think it's just because women are weak, but that is not what it is. But I totally read that. I was like, why weakness now? I think we're more we're more caring. Right. You're better people. You are better people. That's why I also anecdotally, patients who have women physicians have a lower mortality rate. Just putting that out there. All right. And patients have a whole prefer of female doctor. What's that? Even male patients. Patients on the whole prefer a female doctor. I think because we live. Yeah. Yeah. No. So those are a lot of interesting gender differences. It's just swayed by the 60 plus year old men who think you're on nurses. Right. I'm going to get in so much trouble for this. You are. That's all right. You've already blown through two wives. I think you're fine. Don't worry about it. - All right, older, who was less likely to report moral distress, older physicians, so that might include at least some of us on this call, married physicians also less likely to feel to express moral distress than single physicians. I would imagine there's probably some correlation with age as well. So specialty mattered. So compared, the people who seem to have the highest level of moral distress were actually emergency medicine physicians and the group that maybe had some of the lowest were pathologists, which I guess makes sense because they're not actively dealing with, you know, patients' active patients at that time. And then there's like things about practice so more hours, more distress. - Although that was a very weak correlation. - Well, so it is, but what you're looking at those odds ratios realize that they are doing it per additional hour of work week. So per hour, it doesn't look like that much, but if you consider 50 versus a 40 hour work week, that's going to add up. So a lot of times when you have a continuous, I'm going to make the science-y dammit, even if it's supposed to be about distress and burnout, every time when you have a continuous variable, a lot of times you see the odds ratio. And really what that's looking at is per unit. So it'll look small, but when you're talking about a difference of like 10 years, then it starts to add up. That makes sense. And let's see, physicians with high moral distress were far more likely to report burnout, intent to leave, and attempt to reduce clinical hours. So for dermatology, our specialty wasn't the highest risk. And we do, so maybe our work hours aren't, and like you said, Matt, work hours was not the number one contributor to this. But we do have a lot of the same system pressures. And I think we also have a lot, I think this is me kind of editorializing, but we have a high volume of patients, which basically to me means more interactions in which there's potential for moral distress. I think we also have a lot of issues of facing access barriers, prior authorizations. I'd learned at some point that dermatologists prescribe more drugs than any other specialty. So we've got the time constraints, the time pressures, the prior off, the number of interactions. And I think that those all become this fertile ground for moral distress. So punchline burnout, maybe what we feel, burnout might be what you feel like when you're like, my tank is empty. But moral distress is what happens when you're starting to feel like your tank is empty. But you have to keep going, and you're kind of asked to continue to not do what you think is best in your moral, in your professional judgment. So if we want to reduce burnout, it's not going to be just like yoga and taking a week of vacation. We really have to think about ways that we can make sure that we are able to practice in ways that are aligned with what we feel is the right thing to be able to do with our patients. And I really think that that means like empowering physicians. Right? I agree. Laura, like I heard somebody say a doctor say one, if a canary dies in a coal mine, the answer is not to get a more resilient canary. And I think we're all canaries in this coal mine. And slowly we're all dealing with these things. And we need to fix the coal mine in order to help all of us. Yeah, I think that's a great way to put it. So yeah, and I think that there's different ways that we can do that. I mean, one is like advocacy, right? So I can maybe have a better way to fly through prior odds. But like if what I am being asked to do is give suboptimal care, even though I can get to that answer quickly, there's still this level of moral distress, right? So people will say, oh, what we need are more staff. And I do think we need more staff to help us so that we can get to the answer faster. But then I also think advocacy to make sure that within reason we can get what our patients need and that we're not getting roadblock after roadblock from insurers or from systems, right? I work for a big system. Sometimes not always they insurer. It's also sometimes the system not agreeing with us being able to do what we feel is right too. So Dr. Swanson, what is your first, if you had one thing, you could tell your colleagues who are out there struggling, like, you know, just feeling bad, overwhelmed. They don't look forward to going into work. What would you tell them? I think there's so many things burn out. And also there's, I don't think there's a way to like magically fix burn out. Like I don't think there's a magic wand. There is steps you can take to help make sure that you're living your best life and your practice. But even though my burnout was really bad before and then I've made some strides to make it better, it's still there. And there are still some bad days and bad times. And so it is kind of a constant journey of adjustment. I think one of the important things is kind of thinking your head, what would your ideal work environment look like? How many patients would you see in a day? How many locations would you go to? What would be the role of your MA? Would you have a scribe? Would you use AI to scribe? What would your late patient policy be? What would your no-show policy be? What would be your perfect, if you could eliminate all the things that annoy you? What would that look like? And then how different is that from your current practice setup and how changeable could that potentially be? And we're going to have lots of discussion at the end. That's for Patten. What do you got? My deep dive was from a 2024 article in JAMA Network Open title, Physician Engagement and Addressing Health-related Social Needs and Burnout. My tablet to Kelly at all. Health-related social needs or HRSNs or things that can adversely affect patients' health. That may be directly related to their disease, things like food insecurity, housing instability, transportation barriers, etc. And the introduction that offers state that the centers for Medicare and Medicaid services updated the Physician-Fee Schedule to provide compensation for physicians addressing this HRSNs. That was like they do. So yeah, that's a code with G0136. I doubt it. Free and burst is very much, but that is a thing. So anyway, this study was a secondary analysis of a previous survey that was performed in 2022. Table 1 breaks down physician characteristics. Mostly men, about 70% average age, 51 years, mostly white. About a third of physicians surveyed reported high burnout, which meant feeling burnout weekly or more often. Table 2 examines engagement in HRSNs. Overall, it's a third to third and a third reporting low moderate and high engagement respectively. Higher rates of engagement seen for younger physicians, women, black physicians, certain specialties like primary care psychiatry and emergency medicine, like 71% of the emergency medicine engage in HRSNs. Surgeons being very surging and reported never being involved with HRSNs 42.6% of the time. So table 3 gets to the nitty gritty as we would say. And it is engagement in HRSNs related to physician burnout. The answer is yes, moderate engagement associated with 33% higher odds of burnout and high engagement associated with 72% higher odds. That was kind of the overall numbers when they, you tried to break it down like younger, women, minority physician, like it broke down. Like it wasn't a lot of the time statistically significant. But you know, those overall numbers are there. So the point of the paper being like, look, if you can sort of take that burden away from physicians, maybe get social workers involved in things like that, maybe you'd see less burnout. But it's a weird, like, you know, these HRSNs, like food insecurity and transportation. I mean, like once every two or three years, I get a letter from the electric company saying, does this person need their electricity because of the medical condition they have? And I'm like, yeah, sure, that would be helpful. But other than that, like those numbers, like I almost never get involved with HRSN. So is that your experience as well? Like do you see this as something we're dealing with all the time? I think the PDN, I'm curious what Lisa thinks, but pediatric specialists very much do when I see the discussions we have in my department. Pediatric specialists do. And that's partly because, you know, I can, kids can't advocate for themselves. And so if you see this kid is not getting better. because they are not getting the right food or they are not getting the right care. Or they do not have access. Nobody's putting their medicine on. I think you feel a little more obligated whereas we mostly take care of adults. But I do sometimes find it's like, "Here's a great plan." But I know that they don't have transportation or, you know, there's like, there are things. Like, do I have to, do I go in and like, try to get them a car? No, I don't get that engaged. But it changes my plan, right? So I don't know. Lisa, what do you think? How often do you feel like you have to get, like, really involved in this for your pediatric patients? I think it is a really prevalent issue with my pediatric patients, how involved I get varies. We do have a pretty wonderful program with Idaho Medicaid where a lot of these patients will have a case manager. And it's the case manager's job in terms of handling all these logistics. Making sure if they need interpreter services, they get interpreter services. Managing transportation, managing kind of all of their different appointments. And so if I have a patient usually, if they are having some of these issues, they might be on Idaho Medicaid and they might have a case manager. And so I really appreciate that because I think these social issues do come up a lot in the pediatric space. And I think about them and I ask about them. I have never used that code. Maybe I should. Maybe, you know, I'd have a few more nickels to rub together if I use that code. But it is something that we encounter a lot and at least think a lot about in the Piedembourg clinic. Yeah, and I see it as like, you know, there are in on sort of like a smaller level, you know, I have to think about for my patients, like, can you afford a $35 copay? Or do I have to give you something that's got a $10 copay? Or, you know, can you afford, are you really going to go out and buy moisturizers? Are you going to, you know, get the over-the-counter product that I'm like, you know, this is very small scale relative to like, is your family going to get fed tomorrow? But, you know, I do think it impacts the decisions we make. It matters a lot. And I, doing contact term, you get a little bit more into this than other adult specialists because you're often telling people like, you got to get all new stuff and getting all new stuff could be like, you know, 150 bucks. And then is that really going to fix the problem or do I just waste that 150 bucks? Or, I need these, you need these special gloves for work. Well, is your employer going to pay for it? Or can you just buy them just like it was? And so it's one of my characteristics of useful pearls is it has to be cheap. If it's not like, I will never say in a lecture like, oh, here's a pearl, use Skyreasy for granuloma anulare. Don't you fucking moron? You can't do that. Like, it's not, you've, like, so yeah, but I never, other than taking it into account in my making a plan, or acknowledging for a patient. 'Cause, you know, some of the ones who had real trouble with an easy one for us is transportation. Just acknowledging it and being like, oh, that's really hard. And, ooh, I wish I could, you know, just or anything I can sign to help, like that kind of thing. But I think compared to primary care docs, like we do not get real involved with this. I mean, maybe Dr. Swanson does, I could see that. But yeah. - Well, and it's sometimes the best treatment decisions, I can think of one in particular, X-Sama, atopic dermatitis in the kids. A lot of these families will choose something like DuPillumab, because from their perspective, a once a month, SHOT for their little, is so much easier than managing all these different topicals that I might prescribe and just kind of the time it takes for that. If they can think about it once a month, and even if they can, like, come to the office once a month for it, and therefore they aren't having to have, like, personal time invested into it, then a lot of times that's the decision they may, which is fine by me, but it does kind of guide the decision-making process sometimes. - Yeah, the branded drugs are often the cheapest thing for the patient, and that's like a crazy, the $10 copay on a generic that actually costs $12, might be worse for a patient than the $3,000 a month drug that they have copay assistance on. Like, it's hard to accept that this is the system, but put it in. - And also those copay cards can help pay down the deductible for the family. And so sometimes there's even benefit to the family unit in putting one of the kiddos on the viola. - Yeah, and I agree. This is actually kind of one of those things that contributes to dissatisfaction, if not burnout for me, is that, like, I am like, help, you know, you'll meet with payers and they'll be like, "Oh, you guys, you know, they are like, we want to put you in a value-based reimbursement." And you got to really help us to manage costs. And I'm like, okay, great, but like, why are you giving me a prior authorization for method treksate or trium synalone, right? Like, if I'm gonna do the work, I'm gonna get the Cadillac, right? I'm not gonna get like, oh, let me do that and hope that, you know, the trium synalone works so I can then do another prioroth when it doesn't. And like, there's a lack of transparency and, you know, I, like, that stuff is right, 'cause you're like, I'm trying to be, you know, a good steward of dollars. And then you do something dumb, like, you know, I do a lot of psoriasis. Acetretin should be pretty cheap. It's a, it's a perfectly fine option for a certain subset of patients, but it will be way more expensive than sky-resy, for example. So I'm like, all right, sky-resy it is, right? - Yeah. - And you're like, but this is crazy. - It, it's a prize. So it, if we had, if I'd asked you guys before, you heard Pat and talk about this before you ever saw this paper, if somebody had asked you, do you think that physicians who acknowledge and engage with health-related social needs burn out more or less? 'Cause basically what you're asking is like, do the physicians who care more burn out more or less? What would your answer of it? - More. - And I love that you kind of phrased it that way, because sometimes when I'm talking to colleagues that are going through burn out, one of the things I tell them is that I think, I think some of the best doctors who care the most are the ones that get burned out. Because all that caring leads to so much of that moral injury, because you just feel like you're trying your best to be the best you can for your patient. And then these forces are upon you that seem to take priority over the work that you're doing. And that beats you down and it takes away your joy. And so I think the more you care, the more likely you are to get burned out. - Well, I could not agree with that. I think it's you and the reason Pat and it's still practicing. - Well, I wondered about that with this paper. So this paper is like, okay, well, so the more that you're engaged with HRSNs, health-related, sir, yeah. The more likely you get burned out, but I think it's just a baseline personality thing. Like the physicians who have that personality, where they're like, oh my gosh, I have to figure out how this person needs to get to the infusion center. And I have to figure out how they're gonna, and like they're the ones that are like, oh, I couldn't do that. I'm such a terrible doctor. And I kind of want to say like, you need to be a little bit more realistic and practical about how you manage these patients. And it may not be like perfect, but it's good enough and just take that as the win. So I don't know that it's, you know, whatever we say, it's associated but not causative. I don't know that it's causative, like you're engaged, and that causes you to be burned out. I think that's just the personality of the person, and you just kind of overall need to take a step back and say, you're not gonna wind up with like the perfect situation all the time, and that's okay. - And I think like one of the things I've kind of told myself is, you know, like I can try to get the perfect outcome for one person at hours and hours of costs, or I can try to give a reasonable option for one person, but then have like the bandwidth in time to help 10 other people in that amount of time. And at some point, like there are things beyond my control. So I try to do what I can to help that is within my control, but it is in a sense not fair for me to do it at the expense of all of my other patients, or to just say then I don't take care, you know, I don't take, like HS as an example. There are people are just like, I'm just not gonna take care of HS patients. It's too hard. They've got all these psychosocial issues. They've got all these barriers to care. I'll just either, you know, spend all my time on a very few of them, or I just won't take care of them. And it's like, I'd rather have a happy medium where I've got an option and I try to, you know, realize that there's limitations to, I cannot fix 25 years of, you know, history and problems, but at least I can try to do something and help make incremental progress. I don't know if that makes sense. - I think there, what things I always want somebody to do is like detailed psych assessments of medical students like in the first week. And then 30 years later, who's burned out miserable and who's happy because like, so I mentioned it to beginning. Like I have suffered from pretty extreme burnout at some points. And looking back on it was very obvious that that was going to happen. So when I was a kid, my mom used to say, "Oh, Matt, you need to stop. You have the weight of the world on your shoulders." And I would see, it was like when I were kids, they had like the Ethiopia, the people in the, you know, the kids starving and the whatever. And I used to cry because I was convinced that as an adult, the only way that I could be a good person was if I was a missionary in the poorest, most dangerous worst place in the world, I could possibly find because other than doing that, like you're not living up to what God wants you to do. Like that's, that's if you love other people the way you love yourself, you should be like, there's nothing you can do other than you got to get to the worst. But then once you get there, you don't have the resources to help them. So you still can't, and I was crying, crying, crying about this. I should not have been like somebody should have been like, "Oh, I'm going to be a doctor." You're like, you're, you're, you're putting yourself in the like, just every day, it's going to every single patient. When patents like, when Patent said, like some people try and help him get to the infusion center, I was like, "Oh my God, if I had that patient, I'd be so, how are you going to get there? What am I going to do?" And I, well, I wouldn't help him. I would just feel bad about it. Like that's the problem that I had. I almost feel like, what would you have done if you weren't a doctor? I would have been a terrible engineer. I would have been one of the salesman engineers, because nobody would trust me with like, "Yes, I could come up with like the general idea of like, here's what would work." Now somebody else figured out all the details, and I'll sell it to people. That would, that would have been good for me. You know, one of the papers that I looked at and I didn't do was sort of interesting. It was out of Duke. And they looked at, even though it's out of Duke, I can still say it's a good paper. Now I love the Dirk, I love the Duke Derm group. But you know, I think they've done a really great job of trying to think about how to support their faculty. So they sort of did a study on what if we basically just hired more nursing support, and then, you know, you think, "Okay, good. I'll spend less time on the in-basket." But really what they had them do was to just triage more things so that it didn't, they just went into like a spot check or a video visit. And they didn't, I think it's just when you see the overwhelming, like, "I, now I'm worried about this spot. Now I can't get this. Now I can't, it's like, instead of bombarding you with a bunch of stuff that maybe you can help with, or maybe you can't. Somebody else just triages it, so you can show up in the moment and deal with it." Which I thought, like, my first lot was like, "Oh, good, a decreased in-basket time." But I think it almost just like decreased the cognitive burden of just seeing, you know, "I have this problem, I have this problem." And I do think like, "That is one of the things we need to do for people." Even if we can't fix it, you cannot expect physicians to just hear every complaint, take every challenge. And there are so many ways that we can receive those messages. Now we have patient portals, we have emails, we have, you know, all of these, we have reviews online giving us feedback. A lot of institutions love surveys, but they give to the patients. There's so many ways that we're hearing all of this that gets hard too. That gets really hard. I sometimes open up my inbox and I'm like, "Please have nice messages today. Please have nice messages." Yes. Yeah. I actually stop reading my reviews. We get those like every week. I'm 53 years old. This is the doctor I am. I think most people like me and the people that don't like me, it's a personality conflict. It's not they're a bad patient. I'm a bad doctor. We just don't click. And I'm not going to freak myself out about the patient who didn't like me for this, that or the other, because most people do. So I think they're helpful. I tell residents, like read these at the beginning of their career, because you will pick up like a couple of good things. But at this point, yeah. So that's another way of going burnout. Yeah. The other thing, because I do think like there's a little bit like older people are less burned out. Right. And so I do think and I tell them like new. That's what I like. What's that? The reason that the reason that they're still an old doctor is that they didn't get burned out. Well, that's like survived. Survival. So here's my, here's my, my theory. It's that because I'm somebody who went from like being 20 years in one place in practice. And what did I see? I saw lots of return patients. They were people who had chosen to come back to me or their friends who'd been referred to me. So they all came back because they liked me. Then I showed up in a new place where I just kind of got whoever like called the phone room. And they hadn't really picked me. And they had never chosen to come to me. And suddenly I felt like people don't like me as much. I thought, it's because it's the South. And then I realized like it's, it's, you know, I'm like they just don't like me because I'm a Northern. And now I've realized like it, it, it truly is that when you, the longer you're in practice, people come back to you because they choose you, which is means the earlier you are in practice, you're just kind of getting an unselected group of people. And you're not going to have like a connection with as many of them and like just wait it out because it does get better. And you do sort of develop a patient, a type of patient who, you know, clicks with you and they come back. And like for the people who are young and are like this sucks, I'm tired of listening to patients complain. Like it don't go in and try to make every single patient happy. Do the right thing by patients, but give it some time because you are going to sort of build up your patient population. And you are going to like them better. Okay, that's that's pretty good. Fair. Sorry. All right. I've got some, some little vignettes I put together that I want to, I want to hear how you guys would think about each of these. If, if, when they happened to you and they're, there's most of the ones that are very relevant to us as dermatologists. All right. So you're 30 minutes behind. You can see that the waiting room is full. You walk into the room. You see this guy. Like from before you even started the exam, you can see that he's got at least five squames. His field cancerization all over his primary care doctorum. Like, oh, you need to get these take care of your. And you know, this is get like you probably need like 40 minutes with this guy. But every, if that means that everybody else the rest of the day is not going to get like you're going to walk in the room to somebody who's already pissed. And so instead of like, oh, how can I help you? What's going on with your ribs and having a good exchange or you can help them. So what's this, you know, I, at my job, we would never do this and we would blah, blah, blah. And you're trying to explain why. So do you. In the break and lock unless you have the easy answer, I'm just going to handle one today and then have him come back. No, your next appointment, your next available appointment is in four months. And you think it'll be dead from a squame by then. So what do you do? I'll take this one because this does this happens. So one, I do say, wow, you've got a lot of skin cancer and pre-cancer and we didn't get here overnight and we're definitely not going to fix this in one visit. So there's a few things we need to do. One, you've got three things that to me are the most concerning. We're going to buy up see those three. Two, you've got these areas that are so Sunday. I can't tell what's pre-cancer and cancer. So I'm going to give you a cream that you're going to treat it with. Three. Yeah, I noticed I'm looked at, you know, maybe we talk about a prevention thing. And then I say we got to do all these things. And then when one of those is me skiing, when you come back from your visit, I'm going to buy up see another one, but I just say, we you and I are going to get to know each other really well because you're going to be seeing me a lot. So I'm just starting this this process today. And then this is going to be a continued story and relationship. All right. So Ferris short changes the I don't have not a short changing. You know, I think you make you think I come back through this by up to 25 squames in one visit. And then one of them will get it like you'll never keep track of them. I think it is by up seeing three and then starting a treatment plan and going through is the better way to practice than to buy up see 10. I was give Dr. Ferris an A plan. Thank you for that. And I thought, yes, I thought you managed that beautifully. Dr. Padden, what are your thoughts? Yeah, right. This is not we're going to make you better in three. It's not like the horrible psoriasis patient that you can get sky-reasy for and they're going to be better in three months. This is a two year patient and you tell the patient that you're a two year project. I would also say systemic wise things that help. I mean, I've worked with residents that helps because I'll tell the residents. Look, I'll handle the biopsies here. I'll talk to this particular patient about what we need to do for the next two years. You guys clean up the people that have been waiting 30 minutes. I mean, that that is like, OK, well, that's not going to work for me because I'm in private practice fine. You're right. It won't. And maybe that means having really good assistance in your office that can help with a lot of that stuff. stuff. And then finally, just another system-wide thing is, I have add-on visits. I mean, if I look at my schedule two weeks out, I have 30 patients on the schedule. That day, I'll see 38. Because I have these slots where my manager knows, if he sees somebody and he needs to get him back in a month or six weeks or two months, we have those slots. And if they don't get filled, they get filled, right? I mean, the waiting list of people that want to see dermatologist, my office manager would be like, get somebody in that spot. We didn't fill it. We need somebody there two days from now or tomorrow. I mean, those are system-wide things, and maybe not everybody can do that, but that helps out a lot for that. For most people can't. Like, make your office, like, make sure that you have a system where you never have no appointments for four months, right? You've got slots you hold. It is much easier to bring somebody back than it is to feel like I got to do it all right now. I think that's a very important point. We can all-- Let me tell you the scenario now to Dr. Swanson. So Dr. Swanson, you walk in the room, 25 minutes behind. Everybody home. You walk in the room. There's a kid. He's four. He's got horrendous exema. Four-- he's got moms there. She's got five other kids with her, because she doesn't have anybody to whatever. They live four hours away. They said they've been. They're like, oh, it was so hard to get here in the blood. We need-- And like, you know, and you're like, I need-- I need time with this person. I'm already 25 minutes behind. What do you-- and they're four hours away. You live an eye to hope. That's not uncommon for you. No. Yeah. What do you do? I walk right in, like, one fell through, give the dupe accent shot. Just like one felt-- just kidding. Yeah. You could leap through the door. And I hate running behind. It's like my-- I sometimes envy clinicians that running late doesn't bother them, because I feel so much anxiety when I'm running late. It just ruins my day. And I hate the look that you get when you walk in to the patient room and you're late. You can tell on their face just how they're upset with you. And I hate that. I want to avoid that, like, the plague. So I would walk in. I would sit down. I would be not rushed, but efficient in the questions that I ask in the way I have my MA help me. Maybe they can print out the referral. And so then I have the list of previous tried and failed. And I don't necessarily have to spend the time going through all of that. I typically like to give families choices for their treatment plan. But maybe instead of five choices, I write down three. So I'm still giving them some things to choose from, but I'm also being efficient. And recognizing that they live four hours away, maybe your rural environment, what's going to be this setup where they can get the best treatment plan. Do they have access to a compounding pharmacy? So I can use some little tricks in that way. Or would something like do picks and not work? Because they worry about giving the shots on their own. And they live too far away from an office where it can be administered. So I would try to swiftly get through all of that and get them to the point where I can make them better, which is my favorite part. And I have a lot of toys in my office. And so I have coloring supplies and toys. So all six kids can be happy and entertained. OK. All right. All right. Let's go to scenario number two. Insurance companies keep cutting reimbursement and increasing burden on prioroths and everything else. So it's getting to the point that by the end of every day, you finish the impatience at five. You've got an hour and a half. You need to do the prioroth. You need to get through your inbox and call people back. You need to do everything else. But your kids-- like your kids sports games are at 5.30. And do you stay? And so you have the choice between I can feel like a good doctor or I can feel like a good parent. And this is several times a week event. And you could slow down how many patients you're seeing, but then people would have to wait six months for an appointment to get into CU. You could hire more staff. But maybe you're part of a group practice. And they were like, look, you've got the same staff as everybody else. How do you-- let's start with Dr. Ferris, who I would imagine has dealt with this way more than Dr. Patner I have. Although we both have kids, we're probably not nearly as good a parent as Dr. Ferris is. So Dr. Ferris, I mean, so first, is that a scenario that is familiar to you? And how do you-- and I know it's familiar to a lot of our readers. How do you deal with this? Yes. So that is definitely now that I'm an empty nester. It's easier. But yes, there's always been more to do than I have had time in the day to do. So a lot of it is prioritizing. So what will I do? I will leave. I mean, my kids-- we have a friend conversation. Like, I can be there for some things. I cannot be there for everything. I'm probably not going to be the mom who's going to come and photo copy for the teacher six hours a week at 10 a.m. That's probably not going to be me. And I'm probably going to send in store bought granola bars and not homemade granola when there's a thing. And I'm going to opt for, like, bring in the water bottles, not making the game. So a, prioritizing what you're going to do. And then b, I would generally-- and I might be there for three quarters of your game, but not the whole one. But I want it still important to me. And you still matter to me. And then I would go home and do a lot of work at night after I put them to bed. So I would say with having kids, like one of the things I learned is get them on a schedule, have a predictable bedtime. So I knew 8, 15 on was time I could do stuff. So it made it easier to leave, go to the thing, be there present for that activity, and then know that I had time to work later. That's what I did. And the thing that is-- so first, that is very impressive. You're much more disciplined, shockingly, I know, than I would ever have. Because none of that would ever happen at 8, 15. But the thing that drives me insane about that is that our response isn't like-- because every other job in the world, they'd be like, it's your job. You just go home at the end of the day, how much the insurance companies take advantage of the fact that we care. And we don't-- we're the ones sitting there face to face with the patient, who's like, my insurance company is getting-- and you're the one who has to do-- and they so take advantage of that, of that we are good people who care about patients. And it-- I don't-- it's like I don't have an answer, just as so frustrating, because it's like the only answer is fuck the patients. And I don't-- I just-- I think you can also say, we have tried. I have appealed, this is not where we're getting. This is what we're going to try. If it doesn't work, we'll be able to try again. But there is also the like-- everything has to have a-- you do your best, and then you work with the resource that you have. And then you go back, right? And I fight for the things that are worth fighting for. And I maybe-- I fight hardest for the things that are most important to be fought for. Well, largely, though, talking about the idea that inflation-adjusted reimbursement has gone down substantially over the decade. So we're getting more and more administrative stuff, and we can afford less and less staff to help with it. And that's because they know they can take advantage of us. And it's just-- it's maddening. Pat, what do you think about this? About what? Now there are two things. There are kids. The two things. The kids-- you have to stay at home, Maul. You had like an actual parent who's at home to do everything. So that is the answer. Fair. At what point do you think there will be a breaking point where the medical system has taken so many resources away from providers? Like, what's going to happen? I don't know. I don't think on that level. I go in. I see patients. I go home. How the system works. Let it work. I'll figure it out. I just don't get involved. I'm a guy that I deal with whatever's going on. I'm not like, hey, here's how we could make this better. Which is why I do what I do, which is nothing. I see patients. You live in the moment. You say, yes. He's present. All right, Dr. Swanson, what are your thoughts? And then we're going to move on to-- I hope Dr. Patton has some-- he's in Italy. So I don't know if he has-- we'll see if he's got some trivia for us. Dr. Swanson, what do you think about that idea of the system taking advantage of not just physicians, but physicians, PAs, NPs, nurses, [BLANK_AUDIO] everybody who's face to face with the patient. - Yeah. - The hospital administrators, the insurance company people, they just keep squashing us. - Yeah. - 'Cause they, you know. - Well, and it's so interesting because I think it's so much easier for patients to satisfaction to be routed towards us than it is to be routed towards the insurance company, even though it's the insurance company making all of these calls. Because it's hard enough for me to call the insurance company and worm my way through the call line to actually get to talk to somebody. And then even that person can't really enact any change. And so imagine being a patient trying to advocate for yourself, that's just not gonna work. And then have you ever tried to put a Google review for an insurance company? You can't do it. You can't do it. They don't allow it. And so how are they allowed to like be invincible to all of this? And then all of it comes to us. And I wish I had more of Dr. Patton's attitude where I just go in, I do my best job, I go home. That sounds really a lot better. I, my stubbornness gets a hold of me and I feel like every opportunity to fight is my opportunity that I should take. And to quote handmade stale, don't let the bastards bastards grind you down. Like I just feel like it's my role to fight, fight, fight and push back because the only reason they say no and make all of this so hard is because so many people won't fight. And they know that there's a certain percentage of time where they say no, maybe 50% of the people give up. And that saves them money. And so my stubbornness takes hold and I'm like, no, I'm gonna make sure that they pay for it. - So what, just the last thing I gotta add is, I don't know if everybody knows this, that insurance companies are immune from getting sued. So if your, so say Patent has somebody walking with Pemphagus and literally their insurance policy says we will pay for retoximab for Pemphagus. They paid for that policy and the insurance company says nope denied and Patent's supposed to be a PO. Nope denied, we don't pay for that. And Patent says it's another nope denied. We don't pay for that. And Patent does a peer to peer. Oh, you know what it is, it's right there in the policy. We're supposed to pay for that. Oh, don't know how we made that mistake. And the patient died from their Pemphagus in the meantime. Totally immune. That is what the government says called ERISA, ERISA, health insurance companies, and the only thing if you intentionally, if you found something that said, hey, let's try and save some money. We know this is covered, but we're trying, if they're just like, I don't we just screwed up or you know, we're, they are literally immune. Like the federal law cannot do them no matter how much they, if they kill people, can't do. My God, it's crazy what they are able to get away with. Yes, yes. Dr. Green, Dr. The coverage of retoxinab is actually very, very good. I could get it for anything. Anything typically related. Okay, all right. So maybe that's why I don't have the burnout. It's called all, cause I see a lot of these things. And then they don't know the difference and they just approve it. Yeah, that's the trick. Yeah. All right, Pat, and you got the trivia for us this week. I do. So it's it's burnout, burns and quotes. It's all about burning, burning things. Okay, okay. Just once in the rule is you just have, you have to wait for that your patent to finish saying the question. As soon as he's done, you just first person to shout out the right answer, but you only get one guess. Like if you get it wrong, you're out. You can't like shout out a bunch of things. All right. Number one, paper actually ignites at around 480 degrees Fahrenheit, not this temperature as suggested by the title of a Ray Bradbury novel. 451. Fahrenheit 451. Lisa, Lisa, you're muted. Yeah. So unmute yourself so you can answer. I didn't know the answer. It wasn't so I love to be able to blame it on the mute, but I didn't know I saw Lisa mouth Fahrenheit 451. So I'm giving it to her. Yes. I'm going to burn the auto trivia. All right, all right. Point goes the fairs. All right. In the chorus of the 1970s disco hit, disco in Ferno by the tramps, what repeated refrain immediately precedes and follows the phrase disco in Ferno? Burn, baby, burn. Yes. I think the chorus might have a little bit of a pyro. No, no, no, it's all coincidence that I know this. We all know the song, right? Burn, baby, burn disco in Ferno. Burn, baby, burn, burn the mother down. I'm not going to sing because I can't. OK. All right. Number three, I'm in Italy. So I had to come up with an Italy themed question. So Nero reportedly fiddled while Rome burned, which is impossible. The fiddles weren't invented until the 16th century. According to most historians, his death marked the end of what Roman dynasty? Justinian. No. This was-- I thought the first two were guineas, but this was going to be what decided it. But-- Clearly, I know that. --fairs are the ones that I've been asking for. Yeah, this is the luck away when for Ferris. So those first five emperors are considered to be the Giulio Claudine dynasty. And when Nero died, that ended it. There you go. No. Wow. All right. I have-- I feel more really injured by Dr. Pat today. Lisa's burnt out from this podcast. I'm hurt. She'd leave him more burned out than she came in. We've seen it. Yep. All right. Dr. Swatson, it was fabulous having you on the show. This topic was as much fun as it could possibly be. So thank you for coming on and joining us to all of our listeners. Hope you'll have to watch it twice. Hope you learned a few things. But mostly, I hope you're planning to join us again next week. And until then, I'm Matt Zyrus. I'm Tim Patton. And I'm Laura Ferris, and we are Derms on Drugs.