Dr. Weinstein (Part 2): “Adapt or die…standing still is not a zero risk option”
Dr. Michael Weinstein is the President & CEO of Capital Digestive Care. As the largest gastroenterology group in the Mid-Atlantic states, Capital Digestive Care cares for 70,000 patients every year.
In the interview’s second part, Dr. Weinstein talks about how many aspects of the medical practice can be done remotely. He reflects on the future of GI post COVID, his experiences with the giants of gastroenterology (e.g. Dr. Gene Overholt, the father of endoscopy) and what must fellows in GI must focus on. More importantly, he deeply contemplates on social disparity in gastroenterology.
◘ Two learnings: “Telehealth really works…staff can function well remotely”
◘ We’ll get into more chronic care, remote management (obesity, NASH, NAFL)
◘ “George Floyd aside…COVID really increased our awareness how healthcare disparities influences outcomes”
The Transcribed Interview:
Dr. Michael Weinstein: Most physicians within a month figured out a couple of things that they didn’t realize, one is that telehealth really works! You can actually do telehealth effectively. You can actually take care of patients; you can continue to provide healthcare and you can do it remotely. And the second thing that they have learned is those staff that were working in their offices, doing all that work in their offices, can actually function pretty well remotely. Their staff can work from home, a lot of that back-office services can be done remotely – scheduling, registration, claims, billing all this stuff can happen remotely and it doesn’t have to be under your direct vision. And if it can happen remotely with your staff, well then actually, maybe it can happen remotely in a platform where you do not have to worry about people working from home but somebody else can worry about the people who are working remotely.
Praveen Suthrum: What you just said naturally takes me to my next question, what do you see as the future of GI, post the pandemic?
Dr. Michael Weinstein: Certainly, what we see is that we’re probably going to continue to do telehealth. 30 to 40% of our visits will probably stay in telehealth. It may take a little bit of lobbying with the payors and Medicare although I think Ms. Seema Verma recently said “Oh we’re definitely going to have telehealth after COVID”. So, she still certainly feels it is an absolute necessity. The profitability of our surgery centers may lag. I’m not sure whether we will ever get back to the same profitability, at least not for a few years. I think some of the things that we will have to put in place – some of the provisions, some of the PPEs, some of the scheduling modifications to clean rooms, and things like that. I am not sure if we will ever achieve the same profit margins unless we can get a higher payment.
Praveen Suthrum: Don’t you see more cases coming from the hospital to the surgery centers?
Dr. Michael Weinstein: Yeah. But you know, our centers were relatively busy before. Does that mean we’re going to have to expand our surgery center with space and staff and open another room? Most groups probably have a backlog of three or four months of procedures. So, how do we catch up? Assuming that the patients still want to come in, how do we catch up? At some point, we will have to start doing six days a week. But that means hiring extra staff. I think roughly half of the ambulatory procedures in the country are still performed in hospital outpatient departments. So, there are certainly quite a few patients that might shift to ASC locations.
I think we will get into more chronic care remote management. You know it was already starting to happen before COVID. Looking at how do we manage the epidemic of Obesity and NASH and NAFLD and weight management, that’s more chronic disease management. We learned that our clinical research maybe more complicated at least for a few more months of getting patients enrolled into trials because of the number of visits. We are trying to avoid all the face to face contact. That may require some changes in how the sponsors want protocols to take place. And the standard paper binders for clinical research, there needs to be some change to make those electronic.
I have read most of your Scope Forward book, and there are aspects of it that almost predict the need to adapt to COVID. You didn’t know about COVID but the whole concept of innovation and adapting that you have written about, and talk to people about, it’s like… How did he know that we would have to actually meet and discuss and figure out how to adapt to our workflow? I’m certainly very nervous about what I see in Florida and Arizona and Texas. The last thing I would like to see here is a second wave. That would be a financial disaster if we had to close down again. So, I’m hoping we avoid that. I think most of my partners, certainly my older partners, who are in the high-risk groups for COVID, people who don’t do as well when they get infections; most of them are going to wait for a vaccine before they get comfortable. And that’s probably going to be February or March of 2021.
Praveen Suthrum: It is really a precarious time and whichever way I look at it, you know I read all the reports, from clinical to economic, the thing that I really come back to is that nobody really knows. And there are different estimates that keep changing by the week. Yeah so, the way I see it is you have to go with the flow and you figure it as you go along. You have a distant view; and you fold that future in; and you work in that direction but the situation can be very dynamic and it can change quite quickly.
Dr. Michael Weinstein: Adapt or die… adapt or die and that’s it. So, when we did our strategic planning, and some of the partners were very happy where we were, and their comment was ‘Why do we need to change anything?’ ‘We’re doing so well’ ‘Why don’t we keep doing what we’re doing?’ and the consultant said doing nothing is not a strategy. Standing still is risky. Standing still is not a zero-risk option, it is actually a very risky option. Stand still in the middle of a busy street, you’re going to get run over.
So, you have to constantly adapt. That doesn’t mean you have to get it right every time, you may sort of make a maneuver or make a change that doesn’t work out. You need to measure all of the changes that you make and determine whether or not the adaptation is moving you in the right direction. One of the best talks that I ever gave at one of the meetings was, ‘The 10 things I wish I hadn’t done.’ And it was hard to get to 10. I had to cut down from a list of 15 or 20, to get to the top 10 that I wish I had not done! On the other hand, I probably have that list and longer of the things I think, we did correctly. So, so far so good.
Praveen Suthrum: Dr. Weinstein, reflecting back on your own career, going back all the way when you were an early career gastroenterologist. I’m sure you had certain visions about healthcare and where GI would be at this point of time. So, where does that stand? Based on what all you’re seeing going on right now.
Dr. Michael Weinstein: What we’re able to do right now technologically in healthcare is amazing. But then you get a pandemic and you realize how fragile things are. When I first went into practice, I came out of my fellowship and I joined two gastroenterologists. They went from a group of two to a group of three and they had some close friends I could mention some names but, everybody knew this. So, one of my partners trained with Gene Overholt, one of them was close friends with Jim Frakes. You know, I was able to learn from the giants. Because my two older partners made me go spend time with these soothsayers. You know, Gene Overholt, the father of endoscopy, and Jim Frakes who was really this healthcare business savant.
I went up to Minneapolis to meet the leadership of the Minnesota GI group, and looking at how they saw gastroenterologists, and then just paying attention to what was happening in the Mid-Atlantic area, which was a lot of mergers of insurance companies and mergers of hospitals. So, I think within a few years of going into practice I already sort of had the notion that the only way we’re going to be successful is that we have to be more relevant and we need to have our own endoscopy centers. And with the support of my two partners, I built an endoscopy center in 1985 which was very early almost following the floor plan which Gene Overholt had built in Knoxville. So, lucky to do that.
I don’t think I could have foreseen the need to get this big but along the way that seemed to be an obvious change. And it’s not just GI practice, it’s healthcare delivery. I have a partner that likes to say that when he grew up, his father told him that he had two ears and one mouth, that he should listen twice as often as he speaks. So, the idea is to go listen to people who have been through the trenches and have figured out the good parts and the bad parts. Follow the good parts, avoid the bad parts, and pick and choose. So, I feel very fortunate to have been around a lot of those people over a 30-plus year career. It has been a privilege to lead and hopefully lead things a little better. I have three sons and I sort of pass on some wisdom as I said, you get along as you go through life. None of them went into healthcare, but the advice I gave them was, you know, as you go through life, try to pick up after yourself, don’t leave a mess, and try to leave the world a little better off than you found it. That’s the goal.
Praveen Suthrum: What advice do you have for early-stage gastroenterologists?
Dr. Michael Weinstein: Yeah. I love talking to young fellows, maybe because my kids are sort of around that same age. I think if you’re a fellow and you’re looking for a career, that you get to choose your career, you get to choose what you’re interested in and when you go talk to a group, probably the first thing you should ask is – firstly you should say what you’re interested in, what sort of career you see for yourself. Do you want to be an interventionalist? Do you want a career in IBD? Do you want to do liver? Or do you want to do esophagus work? What’s really your passion? Figure out what your passion is and if you’re talking to a group, does your ability to continue to follow your passion fit with the strategic goals of the practice that you’re talking with? The question that you shouldn’t ask first is – How much are you going to pay me? That’s not the first question to ask. First, explain what you love to do and why you want to do that and that’s what I would do.
I think an independent practice has the best of both worlds now. I think independent practice allows with the advent of larger groups. It allows the ability of somebody to subspecialize, to follow a passion within a big group, and to be fully supported in doing that. So, if you want a different equipment, if you want a different schedule to accommodate that kind of patient care, then it is probably easier to get that done in a bigger group then it is in an academic center. You know, they are coming out of their fellowship, they’ve got 30 years to practice. Again, you have to find something you like to do so that you can get up every morning and then do what you like to do. because if you like what you’re getting up to do it doesn’t feel like work.
Praveen Suthrum: Dr. Weinstein, I want to get to a final question and reflect on that a little bit. It is to do with the social disparity in healthcare. Now, whichever way you slice healthcare it’s quite apparent and all these years and probably decades, we’ve probably pushed this under the rug and it’s come to the floor now. So, I wanted to reflect that with you a little bit and read your thoughts.
Dr. Michael Weinstein: Yeah. I have sort of always considered myself very socially conscious but I was obviously been made apparent more so that as much as I thought that I was we weren’t. We got to a situation, and how we got there I’m not exactly sure but, I know that when I went on our website and I looked at all the photographs of all the physicians in Capital Digestive Care, we seem pretty diverse until you sort of start figuring out the ratios and the numbers and you go ‘How did we only end up with you know, such a small percentage of African-American partners?’ In Washington DC this doesn’t make any sense and I’m not sure how we ended up there. We did. And I don’t feel particularly good about it, I mean we have a lot of women partners, and there is certainly an obvious recognition that is in this Washington DC community, that the healthcare disparities led to some very bad consequences for COVID. And that’s the thing.
I think, George Floyd aside I think COVID really increased our awareness of just how much healthcare disparities can affect health outcomes. Because it is very clear that the percentage of deaths is so much higher amongst the communities who don’t have accessible healthcare, who have comorbid conditions that are poorly managed, obesity, hypertension… Their healthcare disparities, their inability to access healthcare, contributed to their deaths. And their inability to access health care has to be on all of us. We may not be able to fix the financing situation, Medicare, Medicaid coverage, fair payment, but that doesn’t mean that we should ignore the fact that health care disparities exist and that if we care about our communities then we need to provide that care.
I’m on the AGA governing board right now. There’s certainly a recognition. I think for everybody, the light went off and we went ‘How did we end up here?’ This is terrible. This was unintended to end up in this situation and we all want to do something; we all want to make it better because we see the problems but the first thing is that we need to understand why it happened. And one of the things I know in gastroenterology is for whatever reason unintended bias or unintentional bias or whatever it is, the African-American contingents in GI fellowship is 25% of what it should be based upon the population distribution. If 18 to 20% of the population is African-American and if 15 to 18% is Hispanic Latino, then how come the fellows are not equally distributed that way and they’re not, it’s terrible, it’s 10% of GI fellows that are ethnically diverse. We need to study that. We need to figure out why that happened and we need to do something to fix it. And it may take a generation, but if we don’t start on that road, we’re never going to get there.
Praveen Suthrum: Yeah and I’m so glad that you’re recognizing it at an industry level. So, what needs to happen that is not happening not just from the physician disparity standpoint but also the patient population, right? A lot of the problems that we see in healthcare don’t really originate in healthcare they go back to the community so it is more upstream. But then insurances don’t pay for going back and fixing problems upstream and where we are, we have created a system that pays for certain things and that doesn’t pay for preventing those things. So, what must happen if you had to freely reflect on ending this?
Dr. Michael Weinstein: There’s no doubt that we have to go upstream. Obviously, we’re a big group in the Mid-Atlantic area in Washington DC, Metropolitan Area, I am not saying that I have any ability to fix the problems in the country but I live in this community, I am a neighbor in this community, I am an employer in this community, and there are things that I can do for my employees, the children of my employees, the communities of my employees, and I may not be able to fix the whole region, but I can start fixing what I can actually affect.
I have to go upstream. I have already talked about providing internships for high school students, for college students spend time in our practice not from all over the country but just locally, that’s the local high schools, the local colleges. We’re going to have a paid summer internship and we’re going to try to increase the interest in healthcare and do things to promote healthier lifestyles in our community. If everybody would look just in their own communities, and if everybody did that there would be a huge change. So, I don’t have a solution for the whole country, I don’t have a solution for Maryland, but we’ve already decided what we are going to do at least in the community that we can touch.
Praveen Suthrum: Excellent. Thank you very much, Dr. Weinstein. Was there anything else that you wanted to talk about?
Dr. Michael Weinstein: No. Love talking to you, love listening to you, love to keep hearing about innovations and things that are on the horizon, new technologies, stuff like that, that will make it easier for physicians to provide healthcare. So, thank you for all you do.
Praveen Suthrum: Thank you so much for saying that and I really enjoyed our conversation and I’m sure that people who are watching this will also do. Plenty of insights right here. Thank you so much, doctor.
Dr. Michael Weinstein: You’re welcome.
By Praveen Suthrum, President & Co-Founder, NextServices.