Season One Episode Two
Brent James, MD: Covid Conversations
Here we are. Welcome to my conversation with Dr. Brent James. Dr. James served Intermountain Healthcare Executive Director of the Institute for Healthcare Delivery Research for more than two decades. He is a member of the faculty at Stanford, and invited lecturer at Harvard and is internationally recognized for clinical quality improvement, patient safety and true culture change. He has trained thousands of clinical leaders in his methods and dozens of these graduates have developed like programs around the world. He has testified extensively before congress and when he speaks, leaders listen. We have a broad ranging conversation that includes novel insights on the Covid-19 pandemic that you don't want to miss. As a statistician he is a rigorous thinker, as a trained surgeon he is deeply knowledgeable about clinical research and care delivery, and as leader, he is an engaging speaker and storyteller. Listen in on The Groves Connection.
Transcript:
The Groves Connection Season One Episode Two features Brent James and Robert Groves, MD. You can subscribe to the podcast here. We want it to be available to everyone, and the transcription follows. It has been lightly edited to remove pauses in speaking.
Welcome. I am Dr. Robert Groves, your host for the Groves’ Connection Podcast. The Groves’ Connection brings you intimate conversations with pundits, providers, patients, leaders and lay people, all to help us understand the contradictions: How can our healthcare system be both magnificent and, yet, so deeply flawed. We’re going inside healthcare to talk candidly to those who know. What they have to say may delight and surprise, or frustrate, or at times even anger you. But, I invite you to listen to the truth about health care and those who want to fix it. Maybe the answers have been there all along. We just need to make the connection.
I am so excited to introduce my guest for this episode: Dr. Brent James is a healthcare legend in the fields of healthcare quality improvement, patient safety, outcomes research and true cultural transformation. And if I listed all of his academic appointments, awards, and achievements, we’d never get to the podcast. He’s a clinical professor at Stanford and invited lecturer at Harvard, a member of the National Academy of Medicine and a consultant to health care systems both across this country and internationally. He’s trained thousands of leaders through his advanced training program at Intermountain Health and spawned several dozen training programs based on his methods. He is a rigorous analytical thinker but also a great storyteller. Dr. James knows how to take a complex idea and make it interesting and relatable, and he’s full of surprises. I open the conversations by asking about his perspective on COVID-19, and you don’t want to miss his response. Please enjoy my conversation with Dr. Brent James.
I want to welcome everyone to my conversation with Dr. Brent James. I am really excited to be here. You and I were speaking earlier, before we started recording, about the first time that I saw you speak. That had to be back in the early nineties. I was a brand new intensivist, newly-minted, and I was chosen to go and attend a workshop at Intermountain Health. And although I had learned about quality management and continuous quality improvement, and the work of Dr. Deming and others when I was at the Veterans Administration Hospital in training, I was interested--but it was not until I heard you speak about it that I got truly excited. And frankly, I spent much of my career at Banner Health working on driving out unnecessary variation in care and establishing a care baseline. We are in the middle of a pandemic, so where I’d like to start today is how do you think about that risk. I’d love to have your perspective on COVID-19.
Dr. Brent James:
You know, it’s all about risk. A lifetime of training in statistics and probability...I find it to be quite helpful. Risks impact how long and how well we live. I regard SARS-CoV-2 as just one more risk in the stack. I tend to track the numbers a bit, and try to come up with the best estimates of how much risk it really represents as a tradeoff; sometimes aggressively pursuing protections against SARS-CoV-2 actually increases or exposes me to other risks. So, it’s a balance, isn’t it?
Dr. Robert Groves:
Right.
Dr. Brent James:
When you really think about it correctly.
Dr. Robert Groves:
And we’re not good at that as human beings. We don’t tend to think statistically.
Dr. Brent James:
Oh, we’re no good at it at all, that’s been very well documented. Many times we tend to be driven more by emotion, by fear. So I like to approach by taking the fear out. Frankly, to be honest, I’m not really afraid of SARS-CoV-2 of COVID-19. It’s a risk, yes. Frankly, in Utah, I track the numbers. I figure the risk of my dying, should I contract it, is...oh...somewhat less than one in a thousand. Compared to other risks I routinely face, it’s a little bit larger--but it’s not completely out of range. Now, that doesn’t mean I’m going to be foolish.
Dr. Robert Groves:
Right.
Dr. Brent James:
Masks are all right. I really like KN95, it is sort of more comfortable to wear than N95s. KN95s are within a hairs’ breadth of being as effective. You’d be an idiot not to use them. Social distancing works. Washing your hands is a good idea in any circumstance. Let’s not get silly here, alright? On the other hand, I think it is a matter of balancing risks and I don’t believe in driving my life in fear.
Dr. Robert Groves:
Let me just ask you a quick question, because I’m fascinated by the one in a thousand: How did you arrive at that number?
Dr. Brent James:
I tracked two things. I try to capture on my computer every major article on the topic. And I try to stay fully up on the science. And the other thing... I live here in Utah, so I track the numbers in Utah every day. So I’ve got a graph on my computer that shows across all age ranges, and it shows in Utah the case fatality rate.
Dr. Robert Groves:
Right.
Dr. Brent James:
The CFR. (Case Fatality Rate)
Dr. Robert Groves:
Do you want to define what you mean by that?
Dr. Brent James:
So it’s among identified cases, how many people die. Currently in Utah, there is about a three-week lag in data, so you have got to lag the data properly--auto-correlation, statistically. It’s .005--that’s where it is running in Utah right now. It’s kind of the centerline.
Dr. Robert Groves:
That’s the case fatality, right?
Dr. Brent James:
That’s the case fatality rate. Now, we know something else. Depending on which literature we believe, there is really not a solid study yet; there are studies in progress, and I’m tracking at least some of them that are in progress...it’s the infected mortality rate. The IFR as opposed to the CFR.
What we know is for every case detected, there are between three and ten people in the community actually who were infected with SARS-CoV-2, and developed a full immune response, but their symptoms were so minor that they chose not to test. They never went in for a test. Three to ten. That means that for a true infected fatality rate, IFR--which is what you really are after for this thing--take that .005, and divide it by a number somewhere between three and ten.
Now the part of my model that I’m leaving out because I haven’t been able to get solid data on it is, it turns out that COVID-19 is very strongly related to age. If you get down in healthier, younger populations, without major comorbid diseases, the fatality rate is even lower. Of course, most of this disease concentrates in the elderly. I’m seventy, I have one major comorbid disease. I’m making guesses about those. You see how I’m getting to my number, though. And then I look at the other dumb things that I routinely do, because of convenience, that I know convey risk. Usually, humans, we’re emotional beings, and we ignore those risks--but in the back of your head you know they’re there. Every time I get in my car and go for a drive I realize I’m taking a small but real risk. I have friends who refuse to get on airplanes because they feel that they’re so dangerous--heavy emphasis on the word “feel.” They are certainly safer than driving in a car. Roughly as safe as the trains that they tend to use to get across the country, and much faster, much more convenient. Of course, you’re in crowds and probably at a higher infectious disease risk, yada yada, yada. There are all those risks you have to balance. Do you see what I mean? So, I think about it. As I mentioned earlier, I’m disappointed in our news media. I think they over sensationalize. And what they are doing is playing off peoples’ emotions, off their fear.
Dr. Robert Groves:
It’s manipulation.
Dr. Brent James:
Ah, yeah, they don’t see it that way of course. But technically, it really is. Their hair catches on fire and then they run around. As a crusty old surgeon who has been a curmudgeon most of my life, I’m not into that.
Dr. Robert Groves:
I’m interested in how you think about the steps that we’ve taken: Okay, masks, hand washing, social distancing, it all makes sense in a novel virus that is sweeping through the population. What else should we be doing? Is it okay to shut down the economy? Or, what’s the balance?
Dr. Brent James:
Well, you said it--you said it exactly right, Robert, and it’s a balance. We know--the evidence is overwhelming--that when you have an economic downturn, it costs human lives. There are a number of different factors, particularly depression. We pay for that in lives. So it is a matter of striking an appropriate balance between the two very early. Also, something else that could’ve helped very early is if we had been able to close our borders. A number of countries have been able to use that fairly effectively, but I think that that particular horse is out of the barn. Once you get a few cases across the line, you are going to have a real hard time limiting them. The idea of more effective testing regimens is certainly very appropriate--finding people who actually have the disease and then getting them into isolation. There are controversies though. For example some would have us basically lock them in a hotel. Incarcerate them in a hotel rather than allow them to be in their home, live within their homes. So there are issues. It comes down to civil rights, balancing civil rights and basic human rights along the way. It depends on how afraid you are, and how far you are willing to go with those things, in terms of how you are balancing them.
Of course, your real hope is to prevent two things: When you have a virgin population and a virus is introduced, you are going to get high, very, very high infection rates. Even if you have a quite low mortality rate, it is still going to show up as a lot of deaths. That’s the situation we’re in. You don’t want to overwhelm the caregiver system. One legitimate argument is that we are really stressing our capacity to care for people who have advanced disease. And what you are doing is you are flattening the curve, pushing those cases out over time. The things we do probably won’t stop people from eventually getting COVID-19. It will just delay when we get it.
Dr. Robert Groves:
Another way of saying that is that the area underneath the curve will be about the same.
Dr. Brent James:
The area will be the same. It is just that you spread it out over time. So, avoiding stressing the capacity of our system is a big goal in all of this--and the other big one is the truly impressive scientific achievement of rapidly producing vaccines.
Dr. Robert Groves:
Wow! That’s an amazing feat.
Dr. Brent James:
Truly an amazing feat, and if we can get to that vaccine availability--of course we are right in the midst of that right now. A lot of angst around that too, but it’s just a matter of time. We’ll get there. Of course we would all like it to happen faster than slower. And you shouldn’t let down your guard in the meantime--the obvious things like this. But we’ll get there. And I predict, when Dr. Fauci said that sometime later this summer that any American that wants access to an effective vaccine will have it...I’m tracking the data, and he’s right. There are a few other vaccines that are hanging in the wings. My personal favorite is Novavax, by the way.
Dr. Robert Groves:
And why is that?
Dr. Brent James:
It is protein-based. Almost all of our vaccine technology is built around, you know, if you get a T Vax, protein-based; Shingles, protein-based; most influenza vaccines, protein based. So we have some novel vaccines too. DNA, RNA, so Pfizer and Moderna are both messenger vaccines. Johnson and Johnson and AstraZeneca are both viral vectors, those are the technologies. It’s not just that you have more trouble handling them, it’s not just that it’s the first time to expose large groups of people to them--and by the way there is a risk in there. You’re balancing risks again. It’s that we have limited production capacity. Novavax will be the first protein based vaccine to cross the line. We know how it behaves, but more important, our production capacity is massive. Novavax says that they will be able to produce 2.1 billion doses in 2021.
Dr. Robert Groves:
And is it easier to transport?
Dr. Brent James:
Yah. It doesn’t require special refrigeration and you can store it in just a regular fridge. It lasts for months. It’s more like our regular vaccines. So I’ve been kind of watching for it. Truth in advertising. They ran a major phase three trial in the UK, just 15,000 patients. They were delayed in starting their trial here in the US. They had trouble with production. But it came live at the end of December and I signed up. I figured I ought to put my body where my mouth is and so I signed up and volunteered for their trial. It’s funny, as an old guy who started doing trials. I started with the Eastern Cooperative Oncology Group working out of Dana-Farber Cancer Institute for cancer clinical trial, GI Tumors. As an old trial guy, they’re randomizing in a really squirrely way. Two thirds of the patients get the vaccine. One third get a placebo when they are going to trial. It should go the other way frankly. If you really want to get the science out fast. So, it is very clearly being affected politically.
Dr. Robert Groves:
Now explain that. Because the strategy that I’m familiar with is roughly half and half.
Dr. Brent James:
That’s the traditional one, it’s half and half. But here’s the trick, the driving statistic in a trial of a vaccine against COVID-19 is the number of people who get COVID-19. So, given what we know about these vaccines, the early phase one and phase two trials, sometimes combined we know that they do have some level of efficacy. The thing that actually determines when they cross the mark is they have to have a certain number of COVID-19 infections, presumably the vaccine on the trial is going to have very, very few. But you are now trying to accumulate COVID-19 infections in the control arm of the trial.
Dr. Robert Groves:
You put two-thirds in the control arm, you are likely to hit that number faster.
Dr. Brent James:
Faster, you’ll hit it faster. But they have chosen to randomize the opposite direction. I think it takes longer, now I’m making an assumption. I’m not truly maintaining equal poise. I’m going into this, I personally believe based on the early data that the early vaccines are efficacious, so I’m going to design in the heat of the moment. Given that we are in the middle of an emergency, I’m going to design a trial for that case. I’m sure I’ve bet somebody is going to say here are the other reasons they did it the other way and I’m just in the [night?] on this, if there is, I’m just not familiar with it.
Dr. Robert Groves:
So, let’s talk about messenger RNA vaccines. Because that’s what everybody’s getting right now. I don’t know how many millions of doses are out there right now, seven?
Dr. Brent James:
They are getting them out there, slower than we’d like. But it’s a really good thing.
Dr. Robert Groves:
So what do you think the risk is now for two vaccines? I guess there is an unknown because we have never done this before.
Dr. Brent James:
Well we have the randomized controlled trials that brought the vaccines not to full approval but to an emergency use approval in the UA. They range about 30,000 patients, so we’ve exposed half of that, two-thirds of that 20,000 patients, 30,000 patients to each of those vaccines at least for short term consequences. When we did the scientific reviews of this, I sat on some national Policy groups and they took us through the scientific reviews. Down in the past we’ve had some minor debacles with other vaccines when we’ve finally exposed a large number of people to them. That’s when you really find out how they behave. The risk of that is very low. So we’re back to balancing risks. What’s the risk of an untoward consequence from an mRNA vaccine that we don’t understand yet versus the risk of contracting and dying from COVID-19? See the idea? Frankly if that were my choice, I’d go with mRNA because I think that is a lower risk than being exposed to COVID-19 if you see what I mean. If I had a good protein based vaccine I perceive that the risk is slightly lower still. So that was why I did it and I figured if I’m sitting around talking about this all the time that I ought to be willing to anti-up. So I went in and got a shot and I’ve been collecting the daily data and blood draws where they track your immune response is some detail so there you go. Give your body to science. I think that is part of being a physician on some level.
Dr. Robert Groves:
It helps to talk to somebody who has a more statistically based mind than I do. I will admit that I get emotional about this sometimes and I’ve let my fear run away with me. It certainly seems to be enhanced by the media and politicized for lack of a better term and the answers are either black or white. In other words either you shut down and don’t leave your house or you ignore and pretend like it doesn’t exist at all. Those are the two options that we are sort of given.
Dr. Brent James:
And they are false choices aren’t they? They really are false choices. It’s gray, it’s nuanced.
Dr. Robert Groves:
We don’t have time for nuance.
Dr. Brent James:
Not in today’s political environment.
Dr. Robert Groves:
Can you put that nuance in a sound bite is the question?
Dr. Brent James:
You can’t and frankly I have the advantage of forty years of scientific research as a physician and statistician. Most people don’t. It’s hard to know what to rely upon in today’s environment.
Dr. Robert Groves:
If you were going to give advice to the lay person out there today. What would you tell them about how to think about all the information that is out there? How do you find the information that is truly valuable in that mess and thinking about thinking, what would your advice be?
Dr. Brent James:
One of the challenges that we’ve really have had is that we haven’t had an authoritative voice that tells the truth. I should say as an aside Robert that I’m disappointed. People get into spin mode where they are trying to spin the public response. So early on, we were having shortages of protective equipment PPE and so we got a national message that we shouldn’t seek masks that masks were not effective. Now, I’m going to say this in a particular way hoping it’s not as harsh as it sounds. That was a lie. Masks are effective. Now let’s be precise at protecting others around you is their primary role. They have a much lower ability to protect you from getting it. But remember that this is a disease where somewhere between two out of three and nine out of ten people who get it are shedding the virus and have no symptoms. It gets worse. There’s a prodromal period of four to six days, so even those who are eventually going to develop symptoms of the virus are shedding the virus for four to six days without any symptoms. The reason you mask up is to protect your loved ones and those around you. It’s a matter of social responsibility. Now if you want to go as far as a KN95 mask, which is what I wear and which is what I saw you wearing when you came in, that will actually protect you to some degree because of how they work.
Dr. Robert Groves:
Reduce the viral load at a minimum.
Dr. Brent James:
Well it will certainly it does the best job of protecting those around you and it will certainly protect you to some degree.
Dr. Robert Groves:
You know my test of that, my measure of the protectiveness of a mask really is does it collapse when I breathe in.
Both:
Laugh.
Dr. Brent James:
Well, I like KN95 because I find them within a hair’s breadth of N95 which is the standard and they are so much more comfortable to wear. I like to wear them better than I like to wear a surgical mask. I’ve spent half my life wearing surgical masks. I find K95 more comfortable because it stands out from your face and it kind of seals against your skin. You can’t wear it without covering your nose.
I think the first thing is we need those in authority to tell the truth. To tell the truth it means you have to trust the people. It means you can’t be trying to manipulate them through some sort of a policy agenda or policy role. Guys, just the truth. I realize it’s complex but most people with a little time can understand even complex truths. You do it routinely, so telling the truth is the first thing. Part of the truth is what we talked about earlier. When I look at it the truth is much closer to I’m not going to hunker in fear.
I think with the new administration that we are much more likely to have authoritative national voices speaking. To the extent that tells the truth, I think it will serve us quite well.
Dr. Robert Groves:
The most troubling thing to me is about the early part of this pandemic was the fact that we weren’t getting the truth from trusted sources. That really sort of poisoned the well for future pronouncements about what to do.
Dr. Brent James:
If you are caught in a lie, you are a damn liar forever. You know I’ve seen statistics that suggest that within the United States the number who trust the mass media is well under 50 percent on both sides of the spectrum. It got worse than that Robert. I’ve got a colleague at Stanford John Ioannidis who was deeply respected across the profession for his work in evidence-based medicine, as he deserved by the way. A very thoughtful voice, he’s a good statistician, he's a data guy. By the way in my department at Stanford when we have faculty meetings, the very same thing emerges very quickly. Their view, well my view is their view, either way you say, the kind of conversations we had with John early on he said you know guys the early data isn’t matching up to the modeling we’re hearing. The modeling that makes it look like it’s going to kill us all pandemic.
Dr. Robert Groves:
Yes there was that modeling early on.
Dr. Brent James:
Oh it was and he was a quiet voice that was saying that guys I’m not sure the data matches. He was savagely attacked in my opinion on social media. It was politically incorrect. So, it’s not just telling the truth in our current medical environment you can be fairly viciously attacked.
Dr. Robert Groves:
From both sides.
Dr. Brent James:
Yes, for telling the truth. Now the trouble with science as you will understand; the story of medicine is a constant, constant conversation to find better versions of the truth. We basically fail to better and better, more accurate versions of the truth.
Dr. Robert Groves:
I like that expression of the process because there is a barrier, because it’s not the best yet.
Dr. Brent James:
It’s never the best. That’s part of the fun, by the way. You can make it consistently better. Looking back, look at the progress of medicine, that’s the story of medicine you see. But to do that it takes the conversation. And we got into circumstances where you couldn’t have the conversation and that’s deadly. When you shut things down largely ideologically, and it has to do with our current political environment as much as anything and the way that social media works, so truth in advertising. I don’t know I’m not on twitter. I track some of my friends on Facebook. I got on Facebook mostly to make sure that nobody stole my name. I don’t believe in those media as a means of effectively truth based communication. I realize I’m a little extreme on that. I’m being a curmudgeon again. But you know, I find my sources of truth from other sources and I appreciate thoughtful, kind of humble voices who give me the full continuum, not black and white.
Dr. Robert Groves:
Do you think the position that we find ourselves in is salvageable? And how do we get back to a better conversation, nationally, locally, with our neighbors? How do we get back to that?
Dr. Brent James:
That’s a harder question. I don’t think there’s a clear answer yet. I tend to be an optimist. I think the pendulum swings. The question is, is how bad does it have to get before the pendulum swings? Now you really want to have a fun conversation? We hear a lot about tribalism in the media today and in our own conversations today. There is an idea that even lies below tribalism. Kind of the foundation upon which tribalism rests. It’s called in-group, out-group. You’ve heard that.
Dr. Robert Groves:
Yes, sure.
Dr. Brent James:
So it turns out humans tend to form groups. Berreby’s book Us Vs. Versus Them [Us and Them: The Science of Identity by David Berreby] by claims that this is evolutionary hardwired into our brains. We are individuals, but at the same time we need a group, a society to survive. If you were somehow excluded from the group for some reason evolutionary history theory it meant your chances of dying went way up. You see it’s really hard to survive as an individual compared to surviving as a group.
Dr. Robert Groves:
So, we’re expanding essentially the idea of clicks in high school. It’s sort of the same thing.
Dr. Brent James:
That’s one example. There are many more. Now you can belong to many groups at one time. But, in in-group out-group, here’s the key thing for out-groups especially if it’s around contention and competition, the enemy they dehumanize the out-group. The thing that people miss on tribalism is this idea of dehumanization.
Another book, it’s called On Killing, [On Killing: The Psychological Cost of Learning to Kill in War and Society by David Grossman] about how we enculturate soldiers to be able to kill in war. It turns out it’s really hard to bring them to kill another human being. And it takes very careful training to get most people to, we have a few people we call them sociopaths who aren’t troubled by this, but for most people it seems to be a deeply ingrained part of human nature. When you dehumanize, what you're saying is that they are not humans. Berreby cites lynchings. In the south states of the United States during the civil rights era, when you read those accounts it’s very apparent that the people that were killing black Americans were de-humanizing them. They didn’t see them as human beings. That’s the thing that I watch underneath it all, is the de-humanizing language and it goes both ways.
Dr. Robert Groves:
It does. It does.
Dr. Brent James:
A hater a bigot these are terms that sometimes apply, but they are used much more generally. You know, “benighted,” “they just don’t understand,” “deplorable,” that’s in-group/out-group language. And it is dangerous. And the question is how bad does it have to get before we finally get over it?
Dr. Robert Groves:
Absolutely. What I’m thinking underneath that. Is that where our anti-science movement comes from? How do we explain people who believe conspiracy theories? Or vaccination conspiracy theories anti-vaccinators? How does that come to be? What is that about?
Dr. Brent James:
So, here’s my belief, this is a belief and you can judge it for yourself. By the way I’ll try and be really careful I say that what I have and here is the evidence. A guy who wrote about that was Jonathan Haidt. He wrote a few very good books in my opinion but in this particular one he talks about the rider and the elephant. So the elephants share emotions and the rider, who in theory is controlling the elephant and directing the elephant is rational thought. He points out that it is a 6,000 pound elephant a 150 pound rider.
Dr. Robert Groves:
And it feels like that so many times.
Dr. Brent James:
And in fact if you extend the argument all the way out to the end, without going into all the detail, with apologies for not going through some of the argument, it turns out that what the rider appears to spend most of its time doing is justifying the decisions the elephant made. Oh, I did mean to go that way!
There is a famous saying in statistics. It came from a turn of the century statistician, he uses statistics like a drunken man uses lampposts for support rather than illumination.
Dr. Robert Groves:
And it’s possible to do that.
Dr. Brent James:
It’s extremely common. You establish a position then you filter the data to back it up.
Dr. Robert Groves:
We all do that.
Dr. Brent James:
We all do that unless you are pretty careful in your thinking we do it all the time.
We want confirmation bias. We want to look at that which re-enforces what we already believe. You know if you have ever studied miss-diagnosis as a physician as you’re looking at a patient, you fairly quickly come up with an idea about what’s causing their problem. You arrive at a diagnosis and then you tend to filter all the data you receive from that point and it’s what leads to miss-diagnosis. Really good diagnosticians they wait longer before they actually commit. That is what happens in that little body of science. That’s what makes you a really good diagnostician, you don’t commit too soon.
John Williamson at Hopkins and later he was at the VA is Salt Lake he came up with a decision support tool that gave you a differential diagnosis. It’s an amazing differential as you work through a patient problem. It has some real advantages. But by having the differential in front of you it meant you didn’t commit too soon. It kept other alternatives on the list and it was associated with a reduction of misdiagnosis rates.
Dr. Robert Groves:
Well Dr. James, now that we’ve gone down that road I’m going to ask you a question. Where does AI come in with diagnostic support? Have you given that thought? Is it always going to be an aid or does it replace at some time?
Dr. Brent James:
So this is a personal opinion, I believe that it will be nuanced. It will always be an aid. And the way to think about it, again it is part of the history of medicine. It’s the core idea behind quality improvement too as currently practiced. In quality improvement in the lean version of quality improvement we would call it mass customization. The idea of mass customization is a way of dealing with complexity. Humans have only come up with two ways of dealing with complexity to my knowledge. Number one is sub specialization also known as the analytical method. If you have a problem that is too big to solve, divide it into a series of small problems. Solve each of the small problems and you solve the big problem. So you subspecialize. You know you are an interest. Internal medicine is pretty broad, well two broad to really master within that you focus on endocrinology. It’s still pretty broad. But within that you focus just on diabetes, narrowing your focus to deal with the complexity. Of course, I’ve got some colleagues here in town that I know that just do cystic fibrosis diabetes. Now you’re getting really narrow.
Dr. Robert Groves:
The danger in that is fragmentation right?
Dr. Brent James:
Exactly. That’s the tradeoff. But the other way, it’s a complementary way that people have come up with to deal with complexity is Mass Customization. A seemingly oxymoron. The key to effective variation standardization. So you establish what is called standard work, a standard protocol, a guideline. But you establish it with that purpose that I’m going to vary around based on individual patients. Now that idea has been around for a long, long time. Lingeis claims to have invented it but that’s not true. For example, back when I was a youngster flying medivac as a resident we in the area used something called a Bird ventilator. Some of us are old enough to remember Bird ventilators.
Dr. Robert Groves:
Yes, I remember Bird ventilators.
Dr. Brent James:
They were probably right on the fringe of your career, but they were a mainstay for mine.
Dr. Robert Groves:
I have poured peep in an Emmerson before so,
Dr. Brent James:
There we go! Old guys rule. I had to be able to field strip one that sometimes stopped working. So you had somebody there to assist you, usually a nurse, who would bag the patient and then you would strip down that ventilator, clean it up and slap together and usually it worked. Can you imagine doing that with a modern ventilator? No, of course not. It’s the history of medicine. John Eisenberg, lead physician at George Washington University Hospital and also the head of AHRQ, John of Arc we use to call him, points out that this is true across the last 300 years of medicine’s history. What we do is we study something and when we start to understand it we standardize it. What it does is it frees the most important resource you have, the trained human mind, the expert, to focus on the things at the cutting edge. See the idea? And if you track the history of medicine, I’ve got lots of examples beyond just a ventilator. What we did was understand ventilation well enough that we built it into the machines so, Dr. Groves intensivist, you don’t have to think about that level of detail. What it means is that you get to focus on other critical things. Don’t you? That matters more in the circumstance. See the idea? That’s AI.
Dr. Robert Groves:
I have used your descriptions, and approaches and sold it to my colleagues based on that for my entire career.
Dr. Brent James:
All of us share that common experience and if you look back we just didn’t put a fancy name on it and try to sell it as a consulting service. But it’s the history of medicine and what it means to be a doctor. I think of it as wings, you know and aircraft wings. So in World War II, a major breakthrough was the P51 Mustang. It was the first wing that had laminar air flow and it massively increased lift on the wing. So you could have shorter wings and get more lift. That’s how modern jets fly. What happens is, they are designed in such a way that the air which is kind of chaotic hits the wing it actually organizes into what they were like little channels of molecules coming across the wing as a little chain, right. Standardized in other words. That’s medicine. The leading edge of the wing is always chaotic.
Dr. Robert Groves:
It’s a beautiful analogy. I like it.
Dr. Brent James:
And then as we work on it and as we understand the structure of it comes back across the wing we standardize it and as a physician I live in the zone of chaos. When I was in training a long time ago, back in the seventies, some of my mentors had been around as young physicians when IV’s were first introduced. And it was a mainstay of their practice. They carried their own tubing in their pocket, their own set of needles. They sterilized their own bottles. Can you imagine doing that today? Well no, we standardized it and pushed it down the line didn’t we? It was a breakthrough at the time. But then a breakthrough becomes routine care. Isn’t that the history of medicine? Isn’t that the nature of progress? But we as physicians, should exist at that turbulent cutting edge and as we standardize things appropriately it takes it off our plate. There is a limited capacity of the human mind and we take our most important resource, the trained expert mind and try to focus it on the stuff that really makes a difference.
Dr. Robert Groves:
I want to ask you about some statements that you’ve made in the past, in fact very frequently, related to that. And one of those is much of what we spend on healthcare, we could have a separate conversation about how much what we actually call healthcare actually impacts longevity. But let’s focus first on health care. You’ve said that, I think it was an Institute of Medicine report that quoted 30 to 50%.
Dr. Brent James:
2010. We called together the experts at the Institute of Medicine, the national academy of Medicine. We were measuring something called quality of associated waste. Deming established it. Deming’s approach is basically a mathematical proof. It doesn’t get much better than that. He was comparing what he called physical outcomes to cost outcomes in process theory. He showed three hard causal links, but two of the three as you improved your physical outcomes. That's what we call quality, attributes of your physical outcomes, in our case clinical outcomes. He demonstrated mathematically that it caused your cost of operations to drop. All right? And that became the core definition for something called quality associated waste.
Okay, that’s great. We know it exists. How big is it? And so we called together the experts and said quality associated waste is how big is it? And the soundbite single line result of that big report was a minimum of 30% and probably over 50% of all spending in health care is quality associated waste. Now, a couple of caveats. It’s true across the world. I work very heavily internationally. My favorite health system, one of my very favorites is Sweden. Their waste rate is going to be about the same as ours. Another one is Singapore. Working with them at the moment as they try to reform their health system. They are all the way up to 3% of their GDP. But their rate of increase is too high so they invited someone in to advise them and reform their health system because of expense. They have relatively high quality associated waste streams, interestingly enough. Same in every country I’ve ever visited if you take a close look.
Dr. Robert Groves:
That’s an important point. I mean there is a perception sometimes among physicians that are interested in this aspect of health care and even among some policy makers that the US’s problems with cost escalation are unique. They’re not, are they?
Dr. Brent James:
Quality waste levels are very similar best I can tell. Alright? There will be some differences.
Dr. Robert Groves:
We just got a head start on them in terms of total dollars.
Dr. Brent James:
We’re optimizing a different function. So, the way to ask the question I had an old colleague, a friend, truth in advertising, Clay Christensen and I were missionaries together in Korea as young men for the LDS Church.
Dr. Robert Groves:
Wow! That’s an interesting connection.
Dr. Brent James:
And Clay did pretty well for himself. I mean the guy who kind of alerted the world to disruptive innovation as a professor at Harvard Business School.
Dr. Robert Groves:
Hey, both you guys are doing okay.
Dr. Brent James:
It worked out that way. Well, Clay approached me and said the key thing in any enterprise, he labeled it the job to be done, what’s the job in health care delivery? Now as you alluded to, it’s not life expectancy. It turns out life expectancy is an extremely poor metric to compare health care systems. It shows a level of stunning naiveté and lack of understanding. The three that emerge the way I like see them, there are other ways of seeing them, look at the work of Tom Reed for example. Now that he’s an expert on this topic. Number one is caring. There is a reason we are called the caring professions. That’s reducing mental and emotional suffering if you will.
Dr. Robert Groves:
We forget that sometimes.
Dr. Brent James:
Oh, do we ever? It’s easiest to see when lives are on the line, but I believe it’s our most important role is the clinician patient relationship.
Dr. Robert Groves:
It is one of the most rewarding by far.
Dr. Brent James:
Yes. You know if you look back before 1900 what we know today if you went to see a typical healer chance of survival went down. Our treatments killed people pretty effectively by any standard that we use today. It’s crazy to look at it. How is it that we were central to human society? It’s all about caring and that hasn’t gone away. Now you have to have the eyes to see it. You have to look to see it. Now it’s there strongly, it’s easiest to see when lives are on the line and someone is dying.
You know Robert what I’ll say as an old cancer guy I think I did some of my very best work when my patients died. I really did. I could change the nature of death. Isn’t that what it means to be a physician?
Dr. Robert Groves:
It is what it means ultimately. We were having a conversation before we started recording and you made a point that my dad made in a different way. When I got into medical school he said what is the number one cause of death? And I said heart disease. He said no. I said lung disease? And he said no. And he says being born.
Dr. Brent James:
Laughter. Ya the mortality rate is still 100%. No one gets out of here alive.
Dr. Robert Groves:
Exactly. And he was making that same point that ultimately the most important thing that we can do for anyone is care.
Dr. Brent James:
Well interestingly when you ask patients, well that’s why I really like Tom Lee’s work, that’s her number one thing. Number two is curing – healing the body, healing the mind where possible some limited ability. On the other hand, yah, it’s 5 to 10% of life expectancy tracks back. By the way Arnie Milstein and Bob Caplan at Stanford in my department just published a really nice summary paper on this topic recently. Currently 5 to 10% maybe 15% if I’m really liberal about life expectancy.
Dr. Robert Groves:
3.6 trillion on that 5 to 10%. And half of that is quality waste.
Dr. Brent James:
Yah. By the way about 40% is your own personal health behaviors, which ties very tightly to your education level. So, the health behaviors are endemic with an underserved population. 30% roughly is genetics. You will joke about how wise you were in selecting your parents, ha ha. Not much to offer there. 20 to 25% is physical environment, social networks, control of epidemic infectious disease, public health. Care delivery is 5 to 10%, if you are really rigorous, maybe 15% if you are quite generous along the way. Now let’s not undermine that, it’s three and a half to seven years of life expectancy on average for every member of our society. So, at my age let’s not get too cavalier, it looks pretty good.
Dr. Robert Groves:
That seven years starts to sound pretty important.
Dr. Brent James:
It starts to sound pretty good, let’s not get too over the top guys. On the other hand, compared to the other sources of health, it is relatively minor. There's literature that says you will get a much bigger health impact by investing in general education. Put that money in general education, more high school graduates, more college graduates, has a bigger impact than putting the same money into care delivery.
Dr. Robert Groves:
So, are we misguided when we talk about social determinants and gosh I’m forgetting the name of the System in New York that is buying hotel rooms for homeless folks because it’s cheaper to keep them in a hotel room than a hospital. Are we barking up the wrong tree there?
Dr. Brent James:
Not entirely. I mean it’s part of the waste modeling. I like to approach it as waste modeling because hospitals are so very, very expensive. By the way we encountered this, I was of course a senior officer in a major health care delivery system. We were being quite successful with our improvement waste elimination efforts, quite successful and the question is how do we use the money? And the question came up should we go address some of those social determinants? Now this is a really good conversation. I recommend it to others. You may come to a different conclusion than us, right. It’s not black and white. Our conclusion was that our primary mission was health care delivery and we should not try to supplant the forces of local and state government with housing and food supply and with education. That is our biggest contribution, we should be part of that conversation, we should be driving it, and we should be convening it. We don’t want the conversation to go away, but we should reduce the cost of health care. So that it wasn’t competing with these other social goods. That was our primary mission. Otherwise what you become is you become an independent taxing agency. Because you are taxing the population with your high health care prices and then I use it for social good. Does that belong to a private organization?
Dr. Robert Groves:
No. That’s a redistribution through a private organization, unnecessary and probably wasteful in all the bureaucracy that is tied up in making that happen.
Dr. Brent James:
We decided that we were going way, way beyond our remit, and way beyond our mission. And we decided that we wanted to be part of that conversation but that we should not try to supplant local and state government. Our problem was that health care costs too dang much. What would happen if you dropped the cost of health insurance by 50%? What would it mean to other programs that we could run?
Dr. Robert Groves:
What would it mean to middle class productivity?
Dr. Brent James:
Yah. Across the board. The question is where we are going to pull unto ourselves? Or where we are going to play an appropriate role in a large society? That’s how we say it.
Dr. Robert Groves:
That’s a very interesting perspective and one I’ve not heard a lot.
Dr. Brent James:
Well, we were being really successful at taking out waste. Across four years we took out 13% of our cost of operations. It was what, Six hundred eighty eight million dollars out of a five billion dollar system.
Dr. Robert Groves:
And this is through essentially mass customization that you described earlier. Having a shared baseline and everybody agrees. Here is what we ought to be doing but yah we are standardizing a lot of stuff and what you used to have to do was remember everything you had to do for every patient. Now what I need you to do is identify when that patient, and this I got from you, is when that patient does not fit that protocol. So you still need to be alert. You still need to be a highly trained responsible physician because otherwise you miss stuff. It’s a different era but it’s still there.
Dr. Brent James:
Yes. All that we’ve done is Robert, we’ve taken a concept that’s been underlying medical practice, good medical practice, the advancement of our profession for hundreds of years and we’re formalizing it a bit.
Dr. Robert Groves:
And start measuring the results.
Dr. Brent James:
And start measuring the results and let’s do better what we came to do. Well we had this conversation and we decided that our mission was to reduce the cost of health care. So should I be buying housing? You know it all started in Denver and it was the city government who was buying the housing to keep people out of the ED. It’s a grand example of this. It’s a population health move upstream quality improvement strategy. Beautiful example. But do we have to do it alone? Should we pull that power unto ourselves? Should we try to replace our elected representatives? It’s anti-democratic and we considered it carefully and decided no.
Dr. Robert Groves:
That’s a new perspective for me that I hadn’t really explored to that depth, so thank you for that. I guess my next question is; why don’t we see results faster nationally? The price of health care continues to escalate. Pharmaceuticals are starting to be an increasingly large percentage. What are we missing? Because we know we can do this. What’s missing?
Dr. Brent James:
There are two main causes that I thing are in play. By the way, this is the whole reason that Arnie Milstein started the Clinical Excellence Research Center at Stanford, I’m a member of that department, is to try and understand that. We are still at the level of how to say it, fairly based opinions but we argue it like crazy. I feel it is two things. One is tradition, habit, existing systems it’s sometimes really hard to turn the carrier. A bigger one for me is misaligned incentives at a particular time.
Dr. Robert Groves:
You are singing my song because the way I think about it is, or used to think about it is self-care. I no longer believe that. The complexity is overwhelming. As I got into the insurance side there is another whole layer of complexity and what I decided is what we need to do is ask the right questions and get the incentives right. And there are a whole lot of smart people who following those incentives will figure it out.
Dr. Brent James:
Well here’s how it works with waste. I have a particular model of waste I like to use. It has some very attractive features to my mind and I need to write it up. I haven’t yet in a formal way. I’ve taught it, but it layers out waste in different layers. It’s really nice because so far as I can tell it gets every source of waste. Most people just kind of heap it all together. It also picks up social determinants and picks up population health quite nicely. It fits the model really nicely. But it layers it out, the big one it ties it out to payment mechanisms. So the way to think about it, any time you are going to do an improvement it always requires an investment. You have to change systems, data systems you bring in new technologies you have to train people, sometimes change your physical plan.
Dr. Robert Groves:
Even sacrifice productivity in some cases especially for learning new systems.
Dr. Brent James:
So there is always a price. The best I can tell is that the price is always paid by the care delivery group. So, I make these changes to care and quite predictably I mean it’s like the sun rising, you eliminate wastes and your costs fall. The question is who makes the investment? And who gets the savings? And it depends on how you are paid. Now, publishing this in Harvard Review a few years ago, it’s a crazy story how it ended up there, but it’s in Harvard Business Review. It laid out the basic layout of the thing. If I am paid a fee for service the only time that the financial incentives align are for areas where I reduce my purchase costs for the supplies I use.
Dr. Robert Groves:
That’s pretty darn narrow. And that doesn’t happen a lot.
Dr. Brent James:
Yah, it’s about 15% of the total waste opportunity when I model it. We debate that by the way. It’s about 15%. So, it’s not trivial. I mean you still want to go through it but the total waste opportunity is about 15%.
Dr. Robert Groves:
Are those supply chain efforts?
Dr. Brent James:
You’ve got it. Supply chain is a classic example. And there even if you are paid fee for service it’s going to benefit, you make the investment, and you make the return. So you can recoup your investment, hopefully with a little bit of overhead left over to do the next round of things.
If you’re paid per case you can pick up a subset of clinical variation. It turns out that payment level is about 25 -30% always, DRGs. You go to a per-case payment system instead of payment for service and you will get the financial alignment for a bigger chunk. But about 45% of waste savings opportunities require that you bump to the level of some form of shared savings. Now my favorite is capitation. That’s where you get full alignment. So the lion’s share of the waste savings requires some sort of a capitated, there are seven or eight versions of capitation by the way, but some sort of a shared savings capitated environment. By the way, some groups in the country are doing really, really well with that. Groups that go all in on care management but you can’t nibble at the edges particular. You are either in or you’re out. These groups demand capitation the reason is it works out so well. So I was working here you know for a so many years at Intermountain. We had our own health plan. So we were effectively capitated for about 35% of our business. The tipping point when I modeled it mathematically, I did the mathematical model I got 23% was the tipping point.
Dr. Robert Groves:
That’s interestingly low.
Dr. Brent James:
It is.
Dr. Robert Groves:
Why is that?
Dr. Brent James:
Well it turns out when I’m being paid for service, I’ll make a margin. The margin is typically small 3 to 5%. Right?
Dr. Robert Groves:
Right.
Dr. Brent James:
What happens, if you are capitated what you are doing is eliminating whole cases. You are moving upstream and one of your primary rolls is to reduce hospitalization rates. You know get better primary care, we published this in Jammin three years ago and we showed that by care management for chronic diseases we could drop our hospitalization rate by 22%. That’s what we published in Jammin you see. Well, think about that, how did the hospital administrator think about that?
Dr. Robert Groves:
Well if they are on fee for service they don’t like it.
Dr. Brent James:
If they’re on per case they don’t like it either. I just nailed their budget.
Dr. Robert Groves:
I remember your comment about icing the hill. What do you want?
Dr. Brent James:
I mean yah. If I go out in Salt Lake weather and the hospital is on a hill and I put the hose out and ice the hill, I’m going to get lots more volume into my EV.
Dr. Robert Groves:
The point is that the biggest opportunity, the biggest margin is in improving quality from a shared baseline and continuing to do that.
Dr. Brent James:
So think of it, if I do the case I have all the expense of doing the case and if I do really well, let’s say I get a 20% margin, that’s quite a high margin for a hospital. 20% of the total spent comes to my bottom line. If I’m capitated and I move upstream and I completely eliminate the case, how much of that do I get? I get 100%. So frankly, for a lot of those cases I’m underwater. I actually lose money every time I do a case. That would be for self-pay or for Medicaid.
Dr. Robert Groves:
The cost center rather than a profit center.
Dr. Brent James:
So that 20% is being extremely generous. So when I modeled it, it came out at 23%. We had big internal debates. The guys in finance where doing this kind of Imperial model as opposed to my mathematical model and even they were getting around 30-32%. And we had a hugh debate between 23 and 32, by the way, and it was great fun.
Dr. Robert Groves:
Both of those are pretty darn low, so yah.
Dr. Brent James:
Finally after days of debate we looked at it all and we said well, it’s something in that range. We’re sure. We said we’re already at 35% at risk.
Dr. Robert Groves:
So this is the point I want you to clarify for us is when you say capitation people my age will think back to the 80’s and they will think what a disaster. Because the cheapest way to take care of somebody with pneumonia is just let them die at home. So you’re talking about a strategy that is very, very different. What is that difference?
Dr. Brent James:
So here’s a link to quality. So, I lived through that same thing as you did and it came during the HMO movement. As we study that there are two things you need to know. The first is that today we have much better measures of quality. So the idea is you actually measure quality and make sure the care giver is actually as subscribed, right? There are real issues around it. That would be another lengthy conversation. You can get there. The second big thing though we did a series of trials back in those days. Most classic was the Duran study and what it showed that under capitation care actually improves slightly. Now, there were subgroups where it may have gotten worse. Overall there was a slight improvement in the quality of care associated with that.
Dr. Robert Groves:
Even back in the days?
Dr. Brent James:
If you actually wanted to look at the evidence as opposed to the ideological argument. What lies underneath it, in my opinion, this is one that I’d be willing to fight for hard though. I think you have to understand the hearts of doctors. I have a joke. They say, say what you will about the human professions, is we are really good at weeding out the sociopaths. To knowingly withhold care from a patient to make money you would have to be a sociopath. And frankly we are not. We select against it. We train the opposite way. It’s heavily, heavily reinforced across your career. Do they occur? Yes.
In my role, when I was at Intermountain there were seven or eight times when I had to deal with people who really shouldn’t be in practice. It was quite rare. And when you find them guys, we have a moral obligation to take them out of practice because they shouldn’t be representing our profession. They shouldn’t be doing this to patients. To be honest with you, in almost every circumstance, well in my experience, every one of them, they were impaired. One fellow had had an injury and actually had some hard to detect traumatic brain injury left behind and his judgement was shot. He started out as a good physician and then had an accident. Most of them are drug or alcohol impaired. Occasionally you got one who was judgement impaired. But we have an obligation to take them out. But the vast majority of our opportunity with good, dedicated, hearts in the right place, committed to patients and we don’t kill patients to make money. And so the underlying logic, I get the logic, it currently doesn’t play through. Now, part of my job was to lay out the ethical choice clearly so people could see it at a functional level.
Dr. Robert Groves:
Make it explicit.
Dr. Brent James:
Make it explicit and then let their good hearts carry the day. Now I believe in physicians and I believe in their hearts. I really do. I truly believe in them as a profession. I think it’s the best profession the world has ever seen.
Dr. Robert Groves:
We have been going, Dr. James, for about an hour now so I think this is a good place to stop or pause and if in fact we move on today I hope that you will come back. This has just been fascinating. I can’t remember a conversation that I’ve enjoyed more. So, thank you.
Dr. Brent James:
Thank you. I’m perfectly willing. I believe in this stuff. I drink my own Kool-Aid. I really believe in it on the evidence. Our opportunities are massive. When you look at the data we could be so much better than we are. No kidding, I mean so much better. By the way it will be cheaper, so our services will be easier for people to use along the way. Can you think of a better way to spend a career?
Dr. Robert Groves:
No I can’t.
Dr. Brent James:
Create that kind of a world. We’re creating a new future for humankind.
Dr. Robert Groves:
Sign me up.
Dr. Brent James:
My trouble is I really believe this stuff.
Dr. Robert Groves:
No. I understand that and I feel it and that is a fantastic place for us to end this discussion with that upbeat optimism about the future of healthcare and our future. And I couldn't agree more. I think we can get there. And when we come back again we are going to explore lots of other topics because I know you have a fascinating mind and I love peeling back the layers of the onion to find out what’s underneath.
Dr. Brent James:
Well thank you. Thank you- you are very kind. Thanks for the conversation. I love these conversations, especially with a knowledgeable person like you.
Dr. Robert Groves:
Thank you very much.