EP. 105: NAVIGATING THE GAPS IN PATIENT STORIES

Mar 26

WITH ILANA YURKIEWICZ, MD

An oncologist and journalist discusses how the fragmentation of healthcare systems puts a strain on clinicians, patients, and caregivers, and how she connects with patients despite the inefficiency and uncertainty created by these shortcomings.

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Episode Summary

It's a cliche to say health care is broken. However, the extent to which it is unnecessarily convoluted, inefficient, and fragmented frustrates even the most experienced clinicians each time they are forced to deal with its consequences. Medical records disappear when a patient switches doctors. Critical details of life-saving treatment plans are buried deep within thousands of pages worth of electronic charts.

In this episode, Stanford oncologist and journalist Ilana Yurkiewicz, MD explores all the ways that modern medicine is riddled with gaps and the incredible strain this puts on providers, patients, and caregivers alike. She is the author of the 2023 book Fragmented: A Doctor's Quest to Piece Together American Health Care. In the first half of our conversation, Dr. Yurkiewicz shares how she connects with patients and helps them through the worst moments of their lives—often taking place after a cancer has been treated. In the second half, we discuss why electronic medical records are failing doctors and patients, how clinicians can strive to retain a sense of autonomy, and how she manages the uncertainty that this broken system frequently imposes upon her.

Ilana Yurkiewicz, MD is a primary care doctor with fellowship training and board certification in internal medicine, oncology, and hematology. She is a clinical assistant professor of primary care and population health in the Department of Medicine at Stanford University School of Medicine.
She has a special interest in cancer survivorship and improving transitions between oncology and primary care. Her practice is uniquely focused on providing comprehensive care for patients with a history of cancer as well as those carrying genetic diagnoses of elevated risk.
As a journalist, she strives to bridge the gaps between academic medicine and everyday lives. She has been a regular columnist for Scientific American and MDEdge. Her writing has appeared in numerous publications and been reprinted in The Atlantic and The Best American Science and Nature Writing anthology.
She is a member of the American College of Physicians and an associate member of the American Society of Clinical Oncology and American Society of Hematology.
In this episode, you will hear about:
• 2:53 - Dr. Yurkiewicz’s day job as a primary care physician specializing in cancer patients and survivors
• 5:49 - The benefits that cancer patients and survivors receive in seeing a primary care provider with additional training in oncology
• 10:34 - What initially drew Dr. Yurkiewicz to oncology
• 15:00 - Why helping people through times of suffering is meaningful to Dr. Yurkiewicz
• 18:30 - How Dr. Yurkiewicz became adept at dealing with the diverse emotional psychosocial of cancer survivors
• 22:45 - What “fragmentation of the healthcare system” means to Dr. Yurkiewicz
• 24:24 - How patients expect the medical system to work versus how it actually works
• 34:30 - The challenges physicians face in piecing together a patient’s story through medical charts
• 39:12 - The consequences of fragmented medical records
• 46:26 - How electronic medical records can be improved
• 50:44 - How Dr. Yurkiewicz retains a sense of autonomy amid a fragmented system
• 58:11 - Dr. Yurkiewicz’s approach to having difficult and high-stakes conversations with patients
Henry Bair: [00:00:01] Hi, I'm Henry Bair.
Tyler Johnson: [00:00:02] And I'm Tyler Johnson.
Henry Bair: [00:00:04] And you're listening to The Doctor's Art, a podcast that explores meaning in medicine. Throughout our medical training and career, we have pondered what makes medicine meaningful. Can a stronger understanding of this meaning create better doctors? How can we build healthcare institutions that nurture the doctor patient connection? What can we learn about the human condition from accompanying our patients in times of suffering?
Tyler Johnson: [00:00:27] In seeking answers to these questions, we meet with deep thinkers working across healthcare, from doctors and nurses to patients and health care executives those who have collected a career's worth of hard earned wisdom probing the moral heart that beats at the core of medicine. We will hear stories that are by turns heartbreaking, amusing, inspiring, challenging, and enlightening. We welcome anyone curious about why doctors do what they do. Join us as we think out loud about what illness and healing can teach us about some of life's biggest questions.
Henry Bair: [00:01:02] At this point, it's a cliche to say that health care is broken. But the extent to which it is unnecessarily convoluted, inefficient and fragmented frustrates and saddens even the most experienced clinicians each time they are forced to deal with its consequences. Medical records disappear when a patient switches doctors. Critical details of life saving treatment plans are buried deep within thousands of pages worth of electronic charts. In this episode, Stanford oncologist and journalist doctor Ilana Yurkiewicz explores all the ways that modern medicine is riddled with gaps and the incredible strain that puts on providers, patients and caregivers alike. She is the author of the 2023 book fragmented A Doctor's Quest to Piece Together American Health Care. Over the first half of our conversation, Dr. Yurkiewicz shares how she connects with patients and helps them through the worst moments of their lives, often taking place after a cancer has been treated. In the second half, we discuss why electronic medical records are failing doctors and patients, how clinicians can strive to retain a sense of autonomy, and how she manages the uncertainty that this broken system frequently imposes upon her.
Tyler Johnson: [00:02:16] This is Tyler, and I wanted to start off today because I feel like this is sort of a proud moment for me, because this is the first time on the podcast that we're interviewing someone who was once a trainee and now is a famous established author and independent physician. But and I can't take any credit for any of the things that Alana has done, but it still is. It's just nice to see someone who you initially knew in that context, who now has gone on to accomplish so many amazing things. So Alana Yurkiewicz, Dr. Yurkiewicz, welcome to the program.
Dr. Ilana Yurkiewicz: [00:02:47] Thank you so much for the kind words. It means a lot to be here and I'm looking forward to this conversation.
Tyler Johnson: [00:02:53] So I thought that maybe we would start off today. You know, usually we have people tell us how they got to where they are, and we are going to have you tell us about that. But first, as a medical oncologist myself, I think that what you do is a little bit unusual and interesting. So I actually thought we would start off by having you tell us, in addition to writing, like what is your day job as a doctor?
Dr. Ilana Yurkiewicz: [00:03:15] Sure. So I do have a pretty unusual day job in that I combined a career in internal medicine and oncology, and my day to day practice is primary care for cancer survivors and cancer patients undergoing active treatment. So I can give a little bit of backstory about how I got here. So I did all of my training at Stanford, I did residency in internal medicine, and then I did a fellowship in oncology and hematology. And throughout my fellowship, I initially wanted to be an oncologist because I saw being an oncologist as being the primary physician for patients with cancer. I wanted to be able to address all of their issues, things that had to do with the cancer, as well as things that didn't have to do with the cancer. And throughout my fellowship, I did see a version of the same story kind of on repeat, which is that after a patient was considered either cured or in remission from their cancer, their oncologist would often say, okay, go back to see your primary care physician. And then a few things would happen. Either the patient didn't have a primary care physician, they might have lost touch with their primary care physician, as they had been in the world of cancer for the last few years. Or another common scenario is that their primary care physician just didn't have the training, or the experience, or the expertise, or the time to be able to address their primary care issues that had to do with the experience they've had with cancer.
Dr. Ilana Yurkiewicz: [00:04:44] So I did the radical thing at the end of fellowship. I think I'm the only graduating fellow from the program that ended up going back to primary care. So I took a faculty position within the Division of Primary Care, primarily, where I opened a practice that does primary care with a special focus on cancer patients and cancer survivors. And so in my practice, I see the spectrum of patients who maybe survived a stage one breast cancer 20 years ago and are still dealing with some long terme effects, as well as patients that are undergoing treatment for perhaps metastatic disease today. And then I also see patients who are considered pre vivors. And I'll put that in quotes, because pre-vivor are patients who are at high risk for some reason, whether it's a inherited genetic mutation they carry, such as a BRCA mutation or a strong family history. And I see those patients in my clinic as well. So it's been a great reward to try to fill in one of these gaps that I felt like I witnessed so often firsthand.
Tyler Johnson: [00:05:49] So we may come back to the Pre-vivor story in a minute, but can you also give a little bit of a flavor? Because, you know, I think a lot of people, including, if we're honest, a lot of oncologists would probably say, well, you know, if you let's say in my world, you have colon cancer, you have a surgery, you get, you know, 3 to 6 months of chemotherapy. Then you go on surveillance and now you're out three, four, five years. There's no evidence of cancer. So it's very unlikely that it's ever going to come back. And now you meet with your oncologist, and your oncologist says, it's been such a pleasure to take care of you. And now we feel like you don't need to be seen by an oncologist anymore. And so, as you mentioned, you know, we say on the medical oncology side, we say you can go back and follow with your primary care doctor. So someone who's in that position, I don't mean this in a dismissive or pejorative sense, but I'm just trying to put the question out there because I think it's the question a lot of people would ask is they would say, well, okay, but what good does it do? What additional benefit does it offer that person to have a primary care doctor who has all of this extra training as an oncologist, as opposed to just going back to their own primary care doctor? I mean, you mentioned some people that have maybe not have a primary care doctor. That's a separate thing. But for somebody who, you know, could just go back to their normal PCP, what benefit does it offer them to go to someone who has the kind of training in oncology that you have? Sure.
Dr. Ilana Yurkiewicz: [00:07:07] So the short answer to that is that even after you're done with cancer and your cancer therapy, the ghosts of cancer, do not. Just disappear without a trace. So there are many what we call in the cancer survivorship world long term and late effects that can happen as a result of malignancy itself, or as a result of the therapies that people receive for malignancy. So long term effects meaning side effects and symptoms that happen during treatment and then persist, for example, neuropathy, cognitive changes, cancer related fatigue, and late effects are things that can come up sometimes years or decades later. For example, developing a secondary cancer. Let's say you develop a sarcoma in your breast after radiation to the breast cancer that was meant to treat the breast cancer and cure it. So there are many things that can happen, some that patients are aware of. Again, like those symptoms like neuropathy or fatigue that they're aware of and some that they're not aware of. Things like decreased bone density, you know, being at high risk for cardiovascular disease, being at high risk for osteopenia, osteoporosis, premature menopause. I deal with fertility in my clinic as well, and planning for fertility for young patients who've undergone cancer treatment. And so even I would say, if you were one of the very lucky ones that went through cancer treatment and did relatively well, there are things that need to be addressed medically. And I, I would say that you get extra benefit from seeing someone who specializes in cancer survivorship for those reasons.
Tyler Johnson: [00:08:45] What about somebody who's undergoing cancer care right now? So I think a lot of people who have been through the cancer journey or have had a loved one who has been through a cancer journey, kind of have a sense that oftentimes when you're going through cancer care, especially if you're actively on chemotherapy, your oncologist in many ways becomes your de facto primary care doctor. That's not always true. Some people keep an ongoing relationship with their primary care doctor, but if for no other reason than convenience, just number of visits a lot of people tend to address sort of primary care stuff with their primary oncologist. So just like with the last question, but slightly different, what additional benefit does it offer to someone who is going through a current cancer journey to have an additional primary oncological care doctor, right, like somebody who is not prescribing their chemo, but who has deep cancer knowledge and is also there to be a primary care doctor in those situations.
Dr. Ilana Yurkiewicz: [00:09:40] I frame my role to patients as akin to what palliative care might do, meaning I frame my role as an extra layer of support for patients who need it. There are patients who are undergoing treatment for metastatic disease who don't need my services, and I won't be offended by that. That's perfectly fine. I think it really depends on the relationship with the oncologist. I think it really depends on the oncologist comfort level, dealing with some of the internal medicine side effects and issues that crop up as a result of cancer treatment, and it depends on the patient's preferences. Like you said, there are some people that just to minimize number of appointments, they might not want to see me frequently, or they see me once a year. And then there are other patients that I see on a regular basis, because that extra layer of support and just being kind of a second set of eyes on everything that's going on with them can be beneficial.
Henry Bair: [00:10:34] Well, thank you very much for illustrating what you do now on a day to day basis. It's definitely something that I have not really come across before. So let's go to the question that we typically start with now that we know what you do now, how did you get to this point? What drew you to oncology in particular?
Dr. Ilana Yurkiewicz: [00:10:54] I was drawn to oncology. I would say as early as my first year of residency, I came into residency undecided. Although looking back at my personal statement, I did say that I was interested in either primary care and or oncology. And it's funny now to read that because I put them both together. But I was interested in oncology because I wanted to take care of very sick patients, and I wanted to take care of very sick patients and kind of the physical sense of the way, but also people dealing with illness that had kind of deep psychological and emotional ramifications. And cancer can wreak havoc on people's lives in so many broad and devastating ways. And I thought it would be just this amazing privilege to be able to take care of people going through that journey, that it puts them in a situation where they're incredibly vulnerable. And I also liked oncology because there's a lot of internal medicine overlap. You know, the way cancer works is that it can wreak havoc on a physical system and on many different organ systems can be affected. And so I felt like it was a field that let me use kind of this broad physiologic background and understanding of pathophysiology, as well as dealing with patients in an emotional way. That was gratifying to me.
Tyler Johnson: [00:12:14] I just want to pause on one aspect of what you mentioned there for a minute. Probably about a year ago, we had on the program Alicia Waldman, and Alicia Waldman is a doctor who kind of reminds me of you in the arc of his career, in the sense that he became an oncologist and loved, in some ways, the sort of helping people through their cancer journey in terms of prescribing their chemotherapy and whatnot. But then as he got further into his career, he recognized that the thing that actually called to him the most was not so much the prescribing chemotherapy, although that was still interesting and meaningful. But the thing that called to him the most was you, I think, used the words psychological and emotional. I think he used the word existential dimensions of helping people through the disease. And so eventually he he sort of started to gravitate and then eventually kind of accepted the fact that most of what he was doing and most of what was most meaningful to him looked more like palliative care than it looked like oncology. So then he eventually took the oncology hat off, did further training in palliative care, and now is primarily a palliative care doctor.
Tyler Johnson: [00:13:19] All of that, though, is to say that I've always remembered and been struck by a story that he told us when he was on the podcast about a woman that he took care of, who I think had had breast cancer, and as part of that journey, had had a mastectomy and then had undergone treatment. And he got to the end of her treatment course. Right. So if you've people who have been through breast cancer will know that that often involves a surgery, which of course, at least initially until reconstructive surgery leaves a woman, often without one or both of her breasts and then radiation and then chemotherapy and, you know, had gone through this for what was, I'm sure, probably the better part of a year and then finally gets all the way through this journey and is on her last her. You know what I think he called the graduation visit where she's like, you know, ready to be done. And he, as the oncologist, thinking of this primarily as a sort of a medical start to finish type journey, was so excited, wanted her to, you know, quote unquote, ring the bell and whatever. And for some reason, during that particular visit, he asked her a question that either he had never asked before or in a slightly different way than he had asked before. And then out comes this flood of tears, and then he all of a sudden realizes that this entire journey had had all of these dimensions and ramifications for this issue. As a very young woman that he didn't even realize were on the radar screen, right. Things about how treatments that she had undergone had affected her sense of herself as a woman, and how it had affected her sense of herself religiously, and how she fit into her community, and how she was viewed by other people, and how she was viewed by her family and all of these other things.
Tyler Johnson: [00:14:57] And he used that as a as a description of the difference or an example of the difference between pain and suffering. Right? That it's one thing to acknowledge the physical pain of undergoing a surgery or having radiation or what have you. But then there's this whole other existential dimension that is the suffering that goes along with that, right? The way that all of those things then affect how you understand yourself and your sort of place in the world. And I hear sort of echoes of that in what you're saying. So can you talk a little bit about what you do in your day job and why that existential element, that suffering element, or helping people as they're suffering, why that's particularly meaningful to you?
Dr. Ilana Yurkiewicz: [00:15:37] And I would add that the suffering can begin at any point, and sometimes it's surprising points of the journey. So one thing that comes up frequently in my practice is telling people, now that I've heard from so many different patients that often the survivorship part of the cancer journey can be the most difficult part, the most difficult transition, because a story that I've heard from so many patients so many times was that when they were going through therapy for cancer, it's like the entirety of their focus was on survival, and it was difficult for a lot of reasons. It was difficult physically when they're dealing with nausea and vomiting and fatigue and neuropathy and so many other things that go along with undergoing cancer treatment. And it was difficult emotionally, but they were just very focused on survival and sometimes hadn't really processed kind of the existential components of going through this therapy. And then it was really surprising to them that only after they, quote unquote, rang the bell and were done with everything did they really begin to process what a toll this has taken on their life. And also a big challenge for these patients is then going back to, quote unquote, normalcy. And many realize that there's no going back to normal. It's only going forward to a very different normal. And that transition from people seeing themselves as perhaps a healthy person to someone who's now undergone this, this really, really difficult medical journey is very, very challenging emotionally.
Dr. Ilana Yurkiewicz: [00:17:14] It's challenging in terms of how they see themselves. It's also challenging in terms of how they portray what they've been through to others. And I've heard many stories of, for example, caregiver fatigue patients whose relationships have unfortunately been just decimated by what they've gone through because their partner in life has gotten tired of being a caregiver. And then there are things like going back to work and how do they share what they've been through. And nobody understands what I've been through and nobody understands why. I need to take time off for X, Y, and Z. And then in young people, I talk about things like dating, like when to disclose, you know, when you're dating a new partner, that you've undergone cancer and, you know, maybe you have infertility or at high risk of infertility, a result of cancer therapies. And so there's a lot to think about that I think people just don't have the mental headspace to think about when they're going through therapy, because again, that focus is just so much on, I want to beat this cancer, I want to survive, I want to live. And then it's only after the fact that they begin to process how to reenter this, quote unquote, new normal. And I think in my practice, one of the most important things I can do is just validate those emotions and help people navigate it in their own ways.
Henry Bair: [00:18:33] So there's a lot there that we don't think about normally in medicine, not even cancer. I mean, like any sort of debilitating, chronic life limiting illness can have those existential psychosocial ramifications that we don't talk about in medical training or in residency. It's just not a skill set that we have been told is important to cultivate. This might be a kind of an odd question, but how did you become comfortable? If you are... How did it become comfortable and adept at dealing with these really weighty issues and diverse issues?
Dr. Ilana Yurkiewicz: [00:19:11] Honestly, I think it's just experience. When you have these conversations on a regular basis, you get used to having these conversations. They feel very normal for me now. They don't feel like they're out of the ordinary. I do follow my patients cues so that every conversation is different. And, you know, I'm I'm still sometimes surprised in a direction that a conversation goes. Sometimes the reason for the visit might just be listed cancer survivorship. And then, you know, the entire visit is devoted to sexual health ramifications from cancer that they weren't comfortable sharing with the medical assistant on the phone. So I've learned to just follow my patient's cues, ask open ended questions in the beginning of the visit. Validate a lot, you know, based on other things that I've seen. And I think you just get comfortable by doing it with many different people.
Henry Bair: [00:20:00] Yeah. One of the services that I rotate through in my internal medicine, you know, my first year of residency, internal medicine is a hospitalist service, so it's run by hospitalists, internal medicine trained physicians. But we only take care of patients who have cancer. It's sort of an interesting service that I had not seen before, like in medical school, where all the patients who are hospitalized on this floor all had some kind of cancer, either solid cancers or blood cancers, leukemias, lymphomas. And yet the reason they were on this service was because they were not hospitalized primarily for a cancer problem. You know, they were they were hospitalized for a blood infection or pneumonia or, I don't know, like a urinary tract infection. And they also happen to have had cancer or happened to currently have cancer and are undergoing chemotherapy. And so this was something that I found myself actually quite fascinated by for many of the reasons that you brought up. You know, we have patients who, on a regular hospital service would just be it's like a simple pneumonia case. But in this case, you know, we have patients coming in with a pneumonia, but then they're also dealing with this lung cancer.
Henry Bair: [00:21:16] And I could choose to go in every day, in the morning to talk to the patient and just focus on the pneumonia. It's like, yes, we're giving you the antibiotics. You're doing better. You know, your white blood cells are coming down. Your inflammatory markers. Markers are improving. You're needing less oxygen. Congratulations. You can probably leave in, you know, in three days. But the awareness that they also have cancer clues me in to the fact that there's probably a lot more I could dig into if I wanted to. And it's so easy to not dig into those things because they're not, quote, part of the job. And yet I've found myself trying to put myself in a place where I feel more and more comfortable in sort of exploring what else might be happening beneath the surface. So I relate very much to what you've said. And, you know, I, I hope to continue being able to explore those dimensions of patient care.
Dr. Ilana Yurkiewicz: [00:22:12] I think it's great that you're recognizing that. Now, I just want to say, and I think this actually might be a perfect tie in to Fragmented, because while it's so important to ask those questions and to see where a patient is, actually one of the things I wrote about in the book is, is situations where patients might be knee deep in these conversations already with their primary oncologist or their primary care physician, and sometimes just you want to do the right thing as a physician, let's say, on the inpatient side. But maybe they're not in a place where they want to talk about those bigger questions at that moment, because they already have a trusted person in their life who they do that with. Or maybe they do because nobody's done that with them before. And in our fragmented system, it's often hard to know these things.
Henry Bair: [00:22:56] Mhm. Yeah. So let's talk about Fragmented. You use a lot of personal stories and experiences to illustrate the ways that our health care system is, quote, fragmented. Before we even get into what you write about in the book, what does fragmentation of the health care system even mean to you?
Dr. Ilana Yurkiewicz: [00:23:12] So I defined it in the book as the insertion of gaps into a patient's story by design that blindfolds healthcare workers to the hole. So the reason I wrote this book is because I think it's become a cliche at this point to say that health care is broken. Everybody who interacts with the health care system, either as a patient, a loved one, or a provider, understands that there are ways that it doesn't work, and I think everybody is frustrated by it. But what came up with me over and over and over again, in all of my training and all of my practice, was this word and this sense that health care was fragmented. And what I meant by that was, as a physician, I felt like I was constantly working in a state where I didn't have access to the full details of a patient's story, to their medical story, to their personal story, to their story that would help me make the best decisions for them. And so I wrote this book to understand and unpack the different ways by which this happens and by which the health care system is designed. Unfortunately, to break up a patient's story into these different pieces.
Tyler Johnson: [00:24:24] You share some really revealing and discomforting stories in the book. I think one of the things that the book illustrates that is really illuminating, especially for people who are, well, actually for both sides, both for those who are involved in health care and those who are not involved in health care is what a big gap there is between what patients may assume is going on in the background and what is actually happening in the background. Right? So if I think of a patient of mine, right, most patients who, let's say, have metastatic cancer are in a very high touch health care environment, right? They're having all kinds of visits, often both with the emergency department and sometimes the inside of the hospital, and then with their primary care team and lots of different specialists. Right. So I might have one patient who I see in a new patient visit, and then I might have them visit a cardiologist and a pulmonologist, not to mention a cancer surgeon and a radiation doctor. And then behind the scenes, there are also pathologists and radiologists and whatever. And then any time they go to an emergency room which may or may not be close to us and then are admitted to the hospital, which may or may not be close to us, etc.. Right. So can you just walk us through for someone who is getting really complex, multifaceted health care like that, what might that person assume is going on and what is really going on in terms of the gaps that exist and the some of the potential places for failure of communication and big resulting problems.
Dr. Ilana Yurkiewicz: [00:25:55] Yeah, that's a great question. So I think patients would realistically assume, first of all, that every single one of those many providers that they're seeing has access to their medical story. And one of my what I mean by that is has access to their medical charts, their medical records, and that their medical records are organized in such a way that that story makes sense, that there's kind of a beginning, a middle and an end, and that there aren't big gaps in some of the experiences that they've been through. So let's just talk about that a little bit more for a second. So I write a lot in the book.
Dr. Ilana Yurkiewicz: [00:26:36] The whole first third of the book is devoted to medical record keeping, because one of the most common things a patient will say to me is, haven't you read my chart or didn't you read my chart? And the assumption is that when they come in to see me, that I will know their medical story. And unfortunately, this is just not the case for so many different reasons. One is what's called interoperability. Meaning when someone transfers from one health care facility to another. So let's say from Stanford to a non Stanford facility, maybe if it's just up the street, there are many places that. Don't share medical records. So sometimes when a patient transfers, those records transfer with them electronically, but very often they don't. Meaning if you are the patient and you didn't actually do the work of contacting medical records beforehand and giving permission to share those records, the new facility just might not have access to those records. So that's one issue. The other issue is how electronic medical records are organized even within one system. So let's say a patient like yours, let's say every single one of those specialists they've seen was even within the same healthcare facility. It is still very possible that a new provider they will see will not have a clear picture of their medical history and their medical story, because the electronic medical records, unfortunately, even in one system, are disorganized, meaning there's dozens and dozens of different tabs where patient data is scattered throughout an electronic ecosystem. I often tell patients that electronic medical records are not written like a book. It's written like where you have to click and click and click and click through different tabs, trying to piece together data to make sense of a patient's history and a patient's story chronologically. And we can get into this, but providers often don't have a lot of time to do that. So let's say you're in primary care and you get a 20 minute visit to see a patient and to do all of that legwork of going through their medical record.
Dr. Ilana Yurkiewicz: [00:28:41] Well, even if technically everything is in the system, the provider might not have a chance to piece it all together in the way it's currently organized. So that's one big thing. So providers might not have access to your medical records in a way that makes sense of their medical story. I would say the other big assumption that patients often have is that they're different. Doctors are directly communicating with each other outside of the medical charts, the medical records. And this unfortunately also is very often not the case. And we can get into the many reasons for that. But I would say a big reason actually has to do with reimbursement and how the fundamental payment model of medicine is today, where it's mostly fee for service everywhere in this country, meaning doctors and health care organizations are reimbursed based on a service they provide. And what is a service? A service is something like a round of chemotherapy, a joint injection, seeing a patient for a visit. But a service is not, for example, conferring with other specialists and conferring with other doctors. And so with this being uncompensated work that's not directly bought out for doctors and other healthcare organizations, there can be very little direct communication.
Tyler Johnson: [00:30:01] Yeah, as I hear you say those things, two things come to mind on the first point. You know, I so like you, I did most of my training at the place that I then ended up getting a job and which is and I'm very heavily involved in medical education. So I watch sort of the entire arc of a person's training as, as they come through the system. Right. And one of the things that has come to strike me as so deeply interesting over time, and which, again, most patients would have no visibility into, is the fact that. So now, as an attending, as the doctor who is ultimately responsible for a patient's care, I have all different kinds of trainees that work with me, right? Medical students, residents, fellows, what have you. And the thing that's so interesting is that in many ways, it is true that the most demanding and time consuming job of the trainee is sorting through medical records, right? It is basically the ability to sort through what is sometimes hundreds literally of pages of documents to distill down the stuff that really matters. Part of that is a learning curve about distinguishing signal from noise. But even once you've developed the skills to to distinguish signal from noise, it is just hugely time consuming because so much of what is there is just fluff, it's just some of it's wrong. And then even the stuff that's right, there's just so much extraneous and duplicative and whatever that there is just to and this is, of course, a point you make in the book, but it's just it is an enormous investment and reinvestment and reinvestment in time to make all of the records, most of which nobody reads or sorts through, so that they can then get rid of it to the stuff that really matters, and to then actually do the sorting to get the information that actually matters out, so that you can present it to the people who actually have to make the decisions.
Tyler Johnson: [00:31:53] By the same token, I do these remote second opinions sometimes. And again, the most valuable service that they provide is sorting through all of the hundreds of pages of medical records to give a little sort of dossier of the stuff that really matters. And it's. Interesting because, you know, anybody who is a whatever fill in the blank, a cardiologist or an oncologist or a rheumatologist, like they know what the signal is. They know what it is that they're looking for, but there is no at least well or widely implemented tool for distilling the voluminous medical records down to the stuff that people actually want to know, which would actually, ironically, be more efficient on both the front and the back end. It would be more efficient in making the records, and it would be more efficient in using them later on.
Dr. Ilana Yurkiewicz: [00:32:47] Yes. And think about how wild everything you just said is that in a field like medicine that's so complex and the stakes are so high and there's so much uncertainty in what we do that the greatest uncertainty can sometimes be in the logistical components of sorting through documents. I find that insane. It's 2024, and 90% of health care facilities still use fax machines. I use fax machines on a regular basis. And, you know, I tell so many stories in the book about not just how this is a waste of time for everybody, but how errors cascade as a result of this. And again, I just find it. It's it's so unconscionable that in a field like medicine where errors can happen for, I would say, better reasons, like just because medicine is really hard and we don't always we can't always predict how patients are going to do that. Errors actually happen so much just because of these logistical failures. And these include errors of omission and commission. So errors of omission where doctors can miss a diagnosis because they just don't have access to the right information, or like you said, they're just sorting through a ton of information and maybe it's all there, but they don't have the time to find the right piece of information that clinches the diagnosis or errors of commission. Like I've been in many situations where I've just repeated a test, you know, because it's too much work to try to find it. Like a patient will tell me. I had a PSA. They don't remember the number. Okay, well, I'm weighing how much work it is for me to kind of track down, let's say, a chest x ray or a blood test or or anything else versus just repeating the test. And, you know, I cite plenty of data in the book about how many doctors have done exactly what I've done. And errors can happen when when you do something that's more invasive, let's say, than just a blood draw. Like there are people who've gotten repeat colonoscopies and then have had a complication from that procedure. And this, again, has just been a result of fragmented medical records.
Tyler Johnson: [00:34:55] So then that was my first comment. And then the second one is that, and I feel like poor Danielle Ofri probably has her ears burning every other time we make an episode, because we refer to this one op ed that she wrote so often, but so be it.
Dr. Ilana Yurkiewicz: [00:35:07] The New York times op. Ed.
Tyler Johnson: [00:35:09] Exactly. But to the point, right? So for those who, if this is your first time listening to an episode, the title of the op ed gives away the thesis, which is the business of healthcare is built on the exploitation of healthcare workers. And to your point, right, the thing that strikes me as being so poignantly unfair is that, particularly in my estimation, for primary care doctors, so primary care doctors, because they don't quote unquote, do procedures, right, they're often paid differently and less than most other forms of doctors. And yet they are the people who are most often responsible for culling through what are often hundreds of pages of medical records, trying to distill the signal from the noise. Most of them do not have house staff or other people to help them with that. And so then they're faced with this. We also talk a lot on the podcast about moral injury, this impossibly morally injurious scenario every single day where it's like, okay, you have 20 minutes to see this patient who you haven't seen in a year and has accumulated 178 pages of medical records since the last time you saw them.
Tyler Johnson: [00:36:19] So what are your choices? Choice number one is to spend the entire 20 minutes going through their medical records, and still do nothing like a thorough job choice. Number two is to basically ignore the medical records and hope they just fill you in on what ever happened and spend the 20 minutes with them. Or choice number three to Daniel offers point, and to what many actually people actually end up doing is spend the 20 minutes with them and then spend a whole bunch of time feeling vaguely guilty that you weren't thorough enough, and then spend a whole bunch of extra time outside of the time that you're supposed to be spending, seeing them culling through the medical records to try to make sure that you didn't miss anything while you're simultaneously missing soccer games and ballet recitals and, you know, whatever, a dinner with your significant other because you're trying to spend all your time just trying to do an adequate job of what is supposed to be your job, because the medical records are such a mess.
Dr. Ilana Yurkiewicz: [00:37:11] And I would add that survey after survey has shown that the number one source of burnout for physicians is bureaucratic tasks, with the EMRs being such a big component of those bureaucratic tasks. So these things absolutely add up. There was a study that recently came out to your point about primary care. Physicians that have primary care doctors did everything they were tasked to do in a day. They would be working 26.7 hour days. And there was another another study that showed that for every eight hours, seeing patients face to face, it generated five plus hours of electronic health record tasks. And so, yes, your choices are you kind of just face the computer and try to squeeze as much of that into the visit as possible, but then you're not making eye contact with the patient. You're not doing the things that you were trained to do in terms of being present with patients, or you take that work home with you, which is what I think most people do. You do it on your weekends, you do it in your evenings. And then an unfortunate result of that is that people are quitting like there's a crisis in medicine, but there is a crisis in primary care in particular, where there's a shortage of primary care physicians. And it's not just because medical students are not going into the field, it's because people are burning out and leaving early. They're retiring when they're 35 or 40 because they're tired of working 90 hour weeks where so many of those hours are spent on paperwork. Like, it's one thing to work hard taking care of patients, but it's really how those hours are spent. And the source of burnout is the time spent on all of these bureaucratic tasks that have to happen just to make the system run. And I think that is one of the kind of great untold stories of medicine today is tying why burnout is happening to the challenges of the electronic medical records and how we can improve electronic medical records to fix burnout in medicine.
Henry Bair: [00:39:12] Almost all the things that you just talked about, I see, like on a daily basis in terms of ordering a new set of labs, fresh set of labs, because we don't want to bother with, like going through paperwork, the hundreds of pages of paper records like we get. I won't name which hospital, but there is one hospital that likes to transfer patients to the hospital I work in. And it's notorious because electronic medical records don't talk to each other, and this hospital always sends patients along with like a massive packet. I don't know why this hospital, even like a five day hospitalization, will be accompanied by like a thousand page packet. I was recently in the cardiac ICU working with 24 hour and it was 2 a.m. and a patient comes in like we get a call from like a transfer from a different hospital, from this hospital, this unnamed hospital. And this patient came and all we knew from like the EMT that was transferring this patient was that he was on. I am not joking. He was on 11 different kinds of drips, continuous medications, three different kinds of pressor medications, you know, medications to help keep the blood pressure up. Because this patient's heart was working so poorly, he was on two different diuretic drips. He was on two different kinds of sedatives. He was on a fentanyl drip. He was on an insulin drip, clearly very complex patient. This patient was intubated, couldn't talk, didn't have a family to come with to give collateral history.
Henry Bair: [00:40:34] This was a Sunday, so we couldn't get a hold of the hospital that was transferring this patient. And yeah, and this patient came in and we're seeing and it was quite a sight, just like the EMTs wheeling him in and like having four different IV poles, each with like 4 to 6 bags hanging. And I remember it was 2 a.m., so maybe it was like the delirium of having worked 20 hours. At this point. I looked at my senior resident and we actually started laughing like, what are we supposed to do with this? You know, we have nothing to work with. We have no one to talk to, no one to work with. This patient is very, very ill. I don't know what to do. And then so we just like we had to start fresh. This person came with the 1358 pages of notes. And I'm not going to read through that. So we just did everything all the labs complete set, all the imaging, get the chest x ray, get the abdominal x ray. No, you know what. Let's just get a CT scan. Let's pan scan. Let's just scan every body part. And then I took me about six hours. I did say over time that morning, six hours to finally piece together like this patient's story. And it was just so unsatisfying. If we knew more about this patient, I could have done something because he was just on these drips for the six hours that I spent trying to piece the story together.
Tyler Johnson: [00:41:47] Henry, before you get to the larger point, I just have to emphasize for audience members who are not familiar with the details of medicine are still young in their training. How absolutely, unimaginably insane that story is, because these medications that the person is on, like this is the kind of person who literally has to have one nurse, like, every second of the day at the bedside, because those 11 drip medications sometimes have to be changed literally from minute to minute. So the idea that it takes an entire team of trained physicians six hours just to sort through the medications for this person who's so sick that their physiology may change in dramatic ways over the course of five minutes, let alone five hours, is just like if you have been in the setting taking care of patients who are that sick. You understand in your bones how that is just unimaginably dangerous and unimaginably incoherent. Like, I can't even think of the right word to describe how absurd that is.
Henry Bair: [00:42:50] And it's not even that atypical. That's kind of one of the points I was trying to make is like, it happens on a on a regular basis, like maybe once a week I get someone like that. I mean, that was probably the worst one I could think of, but it comes close. Often.
Dr. Ilana Yurkiewicz: [00:43:03] Your story is giving me so much tachycardia just because I've been in that situation so many times, and it brings back really scary memories about times in the ICU or the CCU when I had to do the exact same thing. And while it happens in my practice now, you know, at least I'm not taking care of critically ill patients. I mean, the stakes are high, but I often feel like I have more time, at least to sort through all of these details. And if it takes me a month to sort through it, things will usually be okay compared to six hours. But it is applicable to all fields of medicine, and I think every single person listening who has practiced medicine has been in a situation just like that. And like you said, not on an infrequent basis. Like this is just what we do on a regular basis that I think many of the public just has no idea that this is the case. And that was one of the reasons that I wrote this book, was to draw back the curtain and to show what it's like on the other side for physicians and other health care workers, and how we have to manage in a situation with little access to medical information and how that matters. Just so, so, so much and how the stakes couldn't be higher.
Tyler Johnson: [00:44:15] This is a smaller and much less important and dramatic thing. But just to your point, Ilana. Similarly. So we see a lot of patients as second opinions, right? For people who have not yet had a like a super specialized oncologist or whatever. And there is, again, one particular health system which I will not name, but that has a lot of presence here in the area that those who've worked in health care know that when you order lab tests, they're usually done in panels. And so they come in groups of ten or 20 or 30 results, and you can put multiple panels on a page, right. You can put probably 40 or 50 lab results on a page. But there is this one place that every time they don't like sharing their patients very much with other health care systems. And every time they send over a patient, the labs universally are printed in such a way that there is one lab value per page. So you open the the things and it's like the sodium turned the page, the chloride turn the page like it's just it feels like someone is poking you in the eye every time you read through a set of these medical records. It's like a way of saying, we don't want anyone else looking at these, so we are going to make this as inconvenient and time consuming as it can possibly be for you to try to actually go through this.
Dr. Ilana Yurkiewicz: [00:45:27] I'm sure you've also seen medical records where on one page something is right side up, and on the next page it's upside down, and then on the next page it's sideways, and then it's right side up again. And you're, you're like talking your head to the computer screen, trying to figure out what these values you're.
Tyler Johnson: [00:45:44] Like doing cartwheels on your office chair. Right. Trying to keep up with the orientation of the page. If you could see all of our faces, we're all smiling so broadly because this is so universally and ridiculously familiar to us that it's like, you know, some sort of visceral muscle memory just to hear the stories.
Dr. Ilana Yurkiewicz: [00:46:01] And we have to laugh. I mean, like, we have to laugh now, but again, like, again, the stakes are just so high and I just can't emphasize that enough. Just what a travesty this is that we are working in this, that all doctors are working in this state of affairs in the year 2024. And while progress is being made, it is still very, very slow. And, you know, there are better ways we could all be spending our time.
Henry Bair: [00:46:26] Yeah. So one of the things that I wanted to sort of expand upon is that earlier on, we were lamenting the fact that so much of health care is still paper based, like all the faxes. At the same time, we've also lamented at how the EMR seem to add so much to our workload. Okay, then. So how do we make the EMR work for us? I know this is a massive question that could warrant its own episode, but at least just in terms of concrete things that you encounter on a daily basis, if we don't want to go back to the paper records and if the current electronic medical records are not working for us, then what do we do?
Dr. Ilana Yurkiewicz: [00:47:01] Well, I want to be clear. First of all, that I don't want to go back to paper records, and I don't think we should go back to paper records. You know, we can talk a lot about all the negatives of the electronic medical records, but there were a lot of positives, too. You know, I do think EMRs have been a major step up from writing all of this stuff on loose leaf paper where, you know, we're talking about missing data. What if you just literally can't read the other doctor's handwriting or it gets lost in a filing cabinet somewhere? So we are way past that stage, and I think that is a good thing. Emrs have promised to connect all of this data in a seamless way, and I see it more as a story of failed potential and unintended consequences. And so some of those unintended consequences are not actually the result of the technology, but some of the incentives behind the technology that led to the design as the way it is. So, for example, I mean, we can talk a lot about insurance companies and how we need to code things in certain ways in the electronic medical records so that doctors get reimbursed for the visits. And that creates a lot of clutter for then doctors to sort through later that make it difficult to find the needle in the haystack.
Dr. Ilana Yurkiewicz: [00:48:09] But I would say some concrete things that we can do that are already happening, but are just happening slowly. One is a true investment in interoperability. And again, just to define that terms, that means sharing, but not just sharing, integrating data between different health care facilities. So it was around 2009 when paper records were mostly converted to electronic medical charts across the country, and this came as a result of legislation that was authorized and funded by Congress. It was called the High Tech Act, and while most places did this successfully, there was no related stimulus or incentive from Congress that required that the different systems communicate with one another. And so as a result, over time, there's just been hundreds of different electronic vendors that have competed with one another and that have not worked with one another, so that when a patient transfers from here to another hospital up the block, those records could go missing. Now, there are initiatives that also are coming from the federal government that invest in interoperability. And so that means that not just can you share information meaning like a PDF that's 300 pages, but that information can be integrated within another system. So like if you have a potassium level or a sodium level from another facility, their technological solutions now that make it possible to integrate that data across healthcare facilities so that it's truly integrated for doctors to use meaningfully.
Dr. Ilana Yurkiewicz: [00:49:38] So that requires getting rid of some of the incentives that I would say electronic vendors have not to share information. And I would say it's mostly a push from the federal government that's making this possible. I would say another solution that's worth exploring more that is also happening is working better with big tech companies. I find it very ironic that we live well. Two of us on this call live and work in Silicon Valley. You know, I can bike to the Google headquarters in 30 minutes, and yet I can't pull up test results from another hospital up the street. And so in 2018, there were six big tech companies that kind of convened and pledged their assistance to working on interoperability and helping the overcome these technological barriers that get in the way of data sharing from one facility to the next. So I think we can work better not just with the federal government, but with big tech companies, and use the resources of big tech companies to better share information. So those are just some solutions that are being worked on to simplify things.
Henry Bair: [00:50:44] Yeah. I mean, there's even with those proposals. There is like a lot that we can explore. And I'm like very tempted to say that we should probably reserve those questions for like a different conversation because there's so much there. One pretty big question I had was you mentioned earlier that the problems that we face that you yourself face on a daily basis with fragmentation is driving a lot of burnout. Turning back to you yourself. Have you ever experienced burnout? And if not, like, how do you keep going despite all the problems that you face every day?
Dr. Ilana Yurkiewicz: [00:51:25] That's a good question, Henry. I would say I have experienced fatigue. I have certainly experienced exhaustion, physical and emotional exhaustion. I don't know if I've quite met the criteria to say that I have been burnt out, but I have felt all the frustrations that go along with trying to do my best in a system that is just fundamentally fragmented and fundamentally broken. And I think I get through this by I mean, it's going to sound cliche, but by focusing on the rewards and the positives, because there are still so many privileges and rewards that we get from practicing medicine, and I can spend my day lamenting everything that went wrong with the electronic medical records that day, or the hours that I spent fighting with insurance companies trying to get something approved that really just should have been approved all along, and how my time was wasted. Or I can go home at the end of the day and think about a conversation I had with a patient who was really struggling, and how that helped them and how I validated their feelings. Or I ended up referring them, or taking them in a different direction, or focusing on a diagnosis that I made. You know, maybe some other doctors had missed a diagnosis and I was able to diagnose something. And I think the antidote for burnout for me personally, has been trying to spend my time, you know, reflecting on those positives as well as taking the negatives and doing things like writing the book and not just complaining about them, you know, frankly, trying to do something that would actually change things for the better. And for me, journalism has been an outlet to do that. You know, I don't I didn't write this book as just one long form rant. I tried to integrate solutions into it, and I interviewed many people who've had ideas for solutions so that I feel like I am doing my part as an individual to try to help fix this broken system.
Tyler Johnson: [00:53:29] Can I push one level deeper, though, on that, Ilana? You know. The purpose. The ostensible purpose of the podcast is it does many things, but the single most direct impetus was a recognition of the epidemic of burnout, a desire to better understand where burnout is coming from, and a hope that we could help to communicate things that providers can do to help escape the burnout trap. And Henry and I are both big advocates. I think through the course of the podcast, we have become bigger believers in the idea that there is an autonomous zone there somewhere at the center that you were just talking about, where you can still find meaning, right? Where you can still sort of push all the other stuff to the side and then say, this is how I find meaning. At the same time, I'm repeatedly struck by the fact that it's not just that you have these like other orthogonal forces that are sort of out there doing a bunch of things, but that often those other forces, the electronic medical record and the depersonalizing aspects of digitization and bureaucratization and corporatization, all these things are actually, in many cases, actively intruding on the autonomous zone, right? Like they're trying to shrink it further and further so that I think many physicians often feel like there just is no autonomous zone left. Right. It's like they've been consumed by the bureaucracy or whatever. And so I guess that while I totally resonate with you saying you have to find that autonomous zone and that's where you find the meaning, but how do you guard against the encroachment of all of those other forces so that you don't feel like you've just, you know, drowned in them?
Dr. Ilana Yurkiewicz: [00:55:12] I mean, honestly, you can't completely I mean, I try to just focus on the autonomous parts of what I do because there are still so many things of what I do that are not autonomous. So, you know, I give the example of focusing on the rewarding aspects. I do feel like when I'm in a visit with a patient, I am still very much in control of the agenda and the conversation that we're having. And I do feel autonomous. Nobody's telling me how to have that conversation with a patient. Nobody's telling me how to discuss prognosis, nobody's telling me how to work up the symptoms, or whether requires a significant workup of new symptoms that somebody's bringing up. And that's the joy of medicine. And I find great value in that. At the same time, during that visit, I have to chart a note that's written in a very specific way. And those rules were not made up by me. I have to document what's called a 14 point review of systems, saying that I asked about all these other different organ systems and how those were not related to the chief complaint that the patient was presenting for. When I order tests, I have to basically correlate the orders with different codes that would allow those tests to get billed for their insurance and be covered by their insurance. So the patient would not get a big bill at the end of the visit. And then I have to also go through my in-basket, which we haven't talked about too much yet, but is another source, a huge source of burnout for physicians, which is the secure portals of the electronic medical records where everything comes through like refill requests, patient messages, test results, etc.
Dr. Ilana Yurkiewicz: [00:56:51] And in terms of all of those aspects of my day, I am very much not autonomous and there is no way, I think, to guard against that. These are things that just have to be done for medicine to kind of function the way it's set up now. And those are the parts of my job that, you know, maybe they don't quite meet the criteria for burnout, but I would say really, really do frustrate me and make me feel like I am a cog in a machine and make me feel like I'm losing autonomy and losing joy over the parts of medicine that made me want to do it in the first place. And so I don't have a great solution to this. I mean, in lieu of, I mean, some of these large structural changes that I try to push towards in the book of really revamping our system, revamping electronic medical records, revamping a payment model, we're all going to just have to function in this system right now, the way it stands. And I think everybody kind of comes up with their own boundaries and ways of just getting through these non-autonomous aspects of the job. And for me, it's it's just doing them, but trying not to spend all of my energy, all my mental energy being drained by them. Because if you fall into that trap, you will also lose the joy of medicine.
Henry Bair: [00:58:11] I want to end our time together with a topic that you end your book with, which takes a rather personal and ground level turn. As you tell a story of a patient you took care of who was asking you about her prognosis. The question of. Am I going to die? How much longer do I have? And these are questions that many doctors, especially oncologists, have to deal with. And you sort of tie it together with the uncertainty that this fragmented system often thrusts upon us. Can you share with us how you approach those questions in the face of the uncertainty?
Dr. Ilana Yurkiewicz: [00:58:50] So these are questions that everyone in medicine has to deal with. And I think in particular, every oncologist has to deal with patients have asked me the most difficult questions that one can think of. They've asked me, yes, am I going to die? How long do I have to live? How they should spend their last days? And I've developed an approach over the years that has been, I would say, largely informed by lessons from the palliative care field, where I share prognosis first by asking a patient kind of where they are in our fragmented system. I often don't know what other conversations they have had with other providers about their prognosis, whether they've heard absolutely nothing, they don't even know that their cancer is metastatic, or they've gone kind of knee deep into these conversations with a regular doctor. So I ask patients what conversations they've had previously about prognosis. And I also ask how they prefer to hear information. Are they the kind of person that wants all of the details? Are they the kind of person that wants the big picture? Are they the kind of person that wants to reschedule this for when their spouse can be there and they don't want to have these conversations alone? So first, that's just kind of setting the stage and making sure you can have the conversation in a way that's meaningful.
Dr. Ilana Yurkiewicz: [01:00:09] Then when I actually talk about the prognosis, I always do kind of couch it with caveats of uncertainty. And I don't think that's hedging. I think that actually just makes me more honest and realistic. Meaning I can give estimates, but doctors historically are bad at prognosticating. We can be wrong in many directions. We can overestimate, we can underestimate. And so I try to give a best case, a worst case scenario as well as a most likely scenario. And I try to break the fourth wall as much as possible and also kind of couch all of those scenarios with the realities of uncertainty and how they could not be correct and how it's hard to predict. The other thing that I do is emphasize that this often isn't a one time conversation, and just give patients my promise that I will be honest with them based on all the information that I have at my disposal, and that this will be an ongoing conversation with anticipated and sometimes unexpected twists and turns. And my job is just to be as honest as possible as they go through the process.
Henry Bair: [01:01:18] Well, with that, we want to thank you, Ilana, for taking the time to join us for sharing your story. I found it quite inspiring. I found it enlightening. I found it quite satisfying to share my experiences and know that you understand them truly, and that you have written so much about how we can actually fix it. So thank you for for all the work that you've done. We'll be sure to link your book in the show notes to this episode, and I'm sure I'll be very valuable to patients, clinicians, policymakers alike.
Dr. Ilana Yurkiewicz: [01:01:47] Thank you so much. Glad to hear that it resonated.
Henry Bair: [01:01:53] Thank you for joining our conversation on this week's episode of The Doctor's Art. You can find program notes and transcripts of all episodes at www.TheDoctorsArt.com. If you enjoyed the episode, please subscribe, rate and review our show available for free on Spotify, Apple Podcasts or wherever you get your podcasts.
Tyler Johnson: [01:02:12] We also encourage you to share the podcast with any friends or colleagues who you think might enjoy the program. And if you know of a doctor or patient, or anyone working in healthcare who would love to explore meaning in medicine with us on the show, feel free to leave a suggestion in the comments.
Henry Bair: [01:02:26] I'm Henry Bair.
Tyler Johnson: [01:02:27] And I'm Tyler Johnson. We hope you can join us next time. Until then, be well.