Telehealth and virtual care options increased dramatically during the pandemic and have remained high relative to pre-pandemic levels of use. Undoubtedly a good thing when it comes to efficient and timely care, ensuring that quality and compassion remain consistent between a virtual and in-person experience has become paramount. While it may seem counterintuitive, large language models and artificial intelligence have the ability to optimize the telehealth experience, increasing compassion and empathy between patient and clinician. As telehealth has now woven itself into the fabric of the healthcare ecosystem, harnessing emergent technologies is crucial to increase the quality of care and patient engagement.
On today’s episode of In Network's Designing for Health podcast feature, Nordic Chief Medical Officer Craig Joseph, MD, and Head of Thought Leadership, Jerome Pagani, PhD, chat with Matt Sakumoto, MD, a virtual primary care physician and a chief medical information officer at Sutter Health. They discuss advances in virtual and telehealth, and what the future of primary care looks like five to 10 years from now. They also touch on the growing prevalence of team-based care, the power of digital empathy, and building understanding between physicians and patients.
Listen here:
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Show Notes:
[00:00] Intros
[01:06] Dr. Sakumoto’s background
[06:45] Digital empathy in healthcare
[08:01] The role of AI in the future of medicine
[13:21] Primary care informatics and the science behind implementation
[16:05] What primary care will look like in five to 10 years
[18:13] The importance of team-based care
[27:37] Embracing the inbox
[35:58] How health systems can compete with new micro-efficient services
[38:03] Things so well designed, they bring Dr. Sakumoto joy
Transcript:
Dr. Craig Joseph: Well welcome, Matt, to the podcast. We like having you here.
Dr. Matt Sakumoto: Very, very excited, longtime listener, I guess first-time caller, so this is going to be great.
Dr. Craig Joseph: Terrific. So you know, I'd like to start off by just summarizing your background and how you got to where you are. I think our listeners find it interesting. And so I believe you told me the story was that when you were about 11 years old, you heard some epic analysts talking about whether they were going to go to UGM or XGM, and you thought that sounded like a great conversation. You wanted to learn more, and ever since then, that was the direction of your life. Now, did I get that right? Was that 100% on or was I a little off on that?
Dr. Matt Sakumoto: Off by a few years? But definitely having that idea of an epic analyst close to my heart.
Dr. Craig Joseph: All right, well, maybe that maybe I was wrong. So how did you end up where you're at?
Dr. Matt Sakumoto: Certainly, it ended up being a lot of full-circle things. I definitely wanted to do research as a career initially, then realized that I am not that in the lab, should not be allowed anywhere near mice or pipettes. I did a research fellowship and realized that I like hanging out with the doctors a lot more. So it kind of went from what's the research side of things and the biomedical engineering side of things to what does direct patient care look like? And then I kind of realized as I went through medical school residency, I think a lot of engineers think this way. It's like there's so much inefficiency, just an insane amount of inefficiency that drove me nuts. It was like, there has to be a better way. So I got it. I always jokingly, but not so jokingly, say that I got into the informatics world by complaining a lot. And I think that's how a lot of people get in there. So I said, Why are we having to do so much manual chart review? Like, so many clicks? This all seems inefficient. There has to be a better way. And they said you should talk to the informatics people. So that was me during medical school was complaining a lot and then learning how to complain constructively.
Dr. Jerome Pagani: For the record, I just want to note that Matt said that research was harder than practicing medicine. I just want to throw that out there.
Dr. Craig Joseph: Yeah, I don't know what to say sometimes. Ah, dear listeners, sometimes our interviewees get confused, and we'll go back and talk about myself at a later time. So, Matt, you trained to be an internal medicine specialist, and I think the idea was that you were going to go work at a clinic somewhere and see patients and they would come to your office and that is apparently not what happened. Things changed because of this pandemic thing or for other reasons. And the majority of the of the patients you see, or at least a lot of it, is virtual care, how is your life today different than what you thought it was going to be at the end of your residency?
Dr. Matt Sakumoto: Oh, very different. Yes and no. So actually, during medical school, I guess going back to little bit of the personal journey is everyone I knew I wanted to do an internal medicine, primary care or something that involved that long-term relationship with patients. So that was already baked in from pre-med to medical school time. But every primary care doc that I worked with and shadowed, the happiest ones always had some sort of like side gig, either like expert witness things, medical director at a skilled nursing facility, things like that. So I was like, I even knew, I think in medical school that I was not going to be 100% time clinician. I just wasn't sure what that split time would be. And then again, through my constructive complaining, I realized that informatics would kind of be that half-and-half time. But definitely, I think telehealth wasn't quite on my radar. I think I was always interested in how do you provide care beyond the clinic walls. To me, that was more like population health management. How do you do outreach to patients in a kind of more spreadsheet-based pop health outreach? And then I realized probably during clinical informatics fellowship that, oh, there's this thing called telehealth, and people are doing it like it's a little bit and I did fellowship from 2018 to 2020. So on the back end of fellowship, obviously, telehealth blew up. So I was doing a lot of work, setting up clinics, designing clinics, designing, redesigning workflows, basically for how do you kind of take what used to be an in-person thing and train and implement and make things work virtually. So definitely caught and rode that wave from a virtual care standpoint. And then now I currently do basically 80% work from home with telehealth and virtual care-based panel. And then I still go into clinical one day a week, because I want to see patients, and also see the care team, because that's also very important to me.
Dr. Craig Joseph: Alright. Well, so a different experience, but not that different because you're still seeing patients. You're still solving problems. What do you do if you can't solve a problem? What do you do if someone asks about something that you really need to do a physical exam on them or you think that they might need some further care you can't provide from your bedroom?
Dr. Matt Sakumoto: Yeah. And as additional background, so I've worked at a couple of different virtual-only practices previously. My current role and system is I'm part of an integrated delivery network, so I have colleagues that I can send people to multiple clinics, multiple places to send patients to. So I think that's one tenant I always come in with is like always have a backup plan, right? If you're putting on a central line, if it doesn't work out, what's your plan A or your plan B? So when you're starting a telehealth visit, you should probably have an idea of if this is beyond the scope of what you can do, where are you sending patients directly to? And I think that's again, practicing in the integrated delivery network is a lot easier because there's that both trust in me sending patients to my colleagues and then just the patient in general. I'm like, oh yeah, you're part of the system. I can picture where you're going to send me to versus when I was on some third-party telehealth companies. It's like, I'm in California, you're in Alabama, you should go to your nearest urgent care in Alabama, wherever that might be. So just being able to direct specifics to patients, just that trust piece is huge.
Dr. Jerome Pagani: Matt, you've used the term digital empathy in some of your work. What does that mean? How do you apply that in your day to day?
Dr. Matt Sakumoto: Yeah, for me, it's all about connection. Like I mentioned before, like I think I had a, well, initially a research-minded career and then now I think what drew me to medicine was that, that patient connection that being able to have it lodged in the relationship. So when I started doing a lot of telehealth, I realized, how do you maintain that connection, this idea of kind of therapeutic touch, therapeutic relationship when you've never met the person before or yeah, you're not going to be in the same room with them. So I realized that was an interesting thing and a new skill set that I thought I was building. And I was talking with other telehealth colleagues as well that saying like, Oh yeah, we have to learn how to do like a virtual physical exam, but also how do you again, virtually connect with a patient. Secondarily, that there's so many things that we can't do. I can't listen to a patient's heart, I can't listen to a patient's lungs. I can't push on a patient's belly. So there's so much trust that gets built into the patient as well. So building that trust quickly to do a lot of patient reported symptoms and vital signs is also tantamount to when you're trying to do virtual care. So I realized that was a was a skill that needed to be built up. And for me, it's mostly learning through trial and error, probably more error than successes, but slowly getting better.
Dr. Jerome Pagani: There's been a lot of buzz around the interpretation of a recent study that ChatGPT is said to be more empathetic than most doctors. So what do you make of that study that seems to have shown that patients preferred the messaging coming from a large language model to the messaging that comes directly from the doctors?
Dr. Matt Sakumoto: Yeah, I'm glad that they did the study. Lots of caveats. So I think so to put more specifics on it, the study was based off of responses to like a Reddit thread. So there's a difference between how do people respond in a public forum and how do people respond in a one to one relationship with their doctor. So this one was based on how physicians responded or clinicians responded to patient questions again in a public forum versus how ChatGPT or a large language model would respond to that. So again, how you respond again is different in a one to one relationship versus with patients. The one other thing, if I remember correctly from the study, is that the length of the response actually was correlated with higher empathy, so is that better or worse, not really sure. But again, it's slight apples and oranges to like how would a patient and their primary care physician respond back and forth in a private message.
Dr. Jerome Pagani: So we've talked to a lot of folks about the role AI will play in medicine in the future, and it seems like this is a great example of how it might be extensive of what doctors are already doing. Somebody else has pointed out commenting on that study that, you know, yeah, if I had an unlimited amount of time or even enough time, I could draft a very empathetic message. But I'm literally responding to get through this giant list of messages as quickly as I can. Do you think that this is an area where it can actually be an assistive function to doctors and help them be able to do more with higher quality than they're able to do just given time constraints?
Dr. Matt Sakumoto: 100%. And I think that's actually where, again, it's this whole idea of machine versus human versus machine plus human. I think having that augmented turn of phrase I think is actually super helpful. I'm going on a quick aside here, but I think that this does tie in is I've actually started to use either ChatGPT or Bard or some of these other ones to improve just my email messaging with colleagues. So I'll say like, here's my draft, Bard, now go take a crack at this and like, please make this more professional. So there's small little things where it's I'm actually learning from the machine, learning to kind of say like you can soften this phrase here. You can turn the statement into a question. So at least for me, I've actually kind of worked that in. And I think that 100% is analogous to if a clinician is messaging with a patient and saying like, hey, if you phrase the lab result as not clinical, not clinically worrisome versus normal, that might help improve, you know, the patient's reception to that. So I think there is a learning curve that can happen in parallel, but you really have to have humans in the loop. I think that's actually the biggest one is let's play with the tools, but let's keep you in the loop for various reasons.
Dr. Craig Joseph: Yeah. One aspect of empathy that wasn't in that study but I read about it was it was a handout, a kind of a patient or parent handout for a child who was diagnosed with new-onset diabetes mellitus and they let the LLM take a stab at the instructions and focus on the child. So you have to use the right language in the right way. And I've certainly had these conversations as a pediatrician. I'm not an endocrinologist, but, you know, at a higher level. And there was a line that the AI I put in that, again, directed right to the patient using age-specific language, said something along the lines of you may think that you may worry that this is your fault that you got this disease because of something that you did, but nothing could be further from the truth. And I was kind of taken aback by that because that is not something that I would have thought to say to a young child. Now, again, it might be that that's a very common thought, and the pediatric endocrinologists that are listening are rolling their eyes and saying, of course you would say that. But I wouldn't have thought to say that. And that was an eye-opening experience for me. And I think that kind of just leads on, you know, adds on to what you were saying about, hey, teach me, teach me. There are things that I could say better or, you know, or other concerns that the patient's not asking me, but they probably have, and if I could just short circuit that that concern right now, I could make things a lot better.
Dr. Matt Sakumoto: No, totally. I think there's levels of being inspired. I've actually used a lot of ChatGPt things less for taking over work and kind of being like, Hey, I have this vague idea… Actually, a lot of blog titles. I will admit I will feed through and have that be there. So this idea of like this creativity to spark piece, not just like can you generate some that I will copy, paste and use.
Dr. Craig Joseph: And that's funny because everything I write is done by an LLM, and I just say, “Hey, can you write something smart?” And it, you know, it's pretty good. Most people say it's better than what I've done by myself. So I'm excited about that. Alright, Matt, you recently led a panel at AMIA focusing on primary care informatics. And I was there. I was in the audience. It was great. I have just a few questions about it. First of all, what is primary care informatics? What the heck is that?
Dr. Matt Sakumoto: I mean, it's hard enough to define what informatics is, right? And then primary care informatics, it's everything and nothing all at once. I think for me, primary care informatics is how do we just improve patient care and clinician wellness through both better workflow design and all the tools that we use. So I keep it necessarily broad, more so because it also provides me with more job opportunities, but also keeping it broad. I think there's so much again, primary care covers a large swath of medicine, and then obviously informatics also has everything from designing software to putting that software into, you know, a workflow that multiple people are part of. So for me, that encompasses all of those pieces.
Dr. Craig Joseph: Yeah, that's great. Primary care is something and nothing all at the same time, and I've seen it either, you know, written as the key to our future or completely irrelevant. And I think somewhere in between speaking as a primary care doc somewhere between is probably the right answer as well. So at this, at this primary care informatics panel, you were talking with a professor who talked about implementation science. And I was fascinated by this term. I had never heard implementation science, or at least not long before that. What do you think is implementation? What is that? How do we leverage that? In the past, it was just, hey, I got to implement this new technology, or I have to implement a new workflow. And we just did it. And apparently there's science now, is that true? Did I get that right?
Dr. Matt Sakumoto: Oh, totally. And like I said, I will do a shout-out to Theresa Walunas, who is a professor there. So she was one of my first mentors in clinical informatics. I think that's a lot of things where I realize that it's not just the technology, so it's the ability to do both design and technology. But that technology adoption piece is so important, right? You know, if you build it, they won't come, like you have to sell it. You have to like, make sure it works, make sure it works in the workflow. So all of those ways of thinking about that, that's definitely inspired by her. And she continues to lead in that field of implementation science. I think it's one of those things where there are different ways, different theories of how people adopt things, how people use things, how you can kind of seed adoption with one group and have that inspire another group. So all of these things, I think there's a science of delivery that is super important and I continue to learn of her and then that field.
Dr. Jerome Pagani: Matt, I think when most people think about their doctor, they're thinking about a primary care doctor, somebody who establishes a relationship with them over time and helps kind of guide them through their health journey. Right? What do you think primary care is going to be like five to 10 years from now? And are you designing workflows and systems that's going to help bridge from where we are today to sort of what that future state looks like?
Dr. Matt Sakumoto: Yeah, I think that the, my model I’ll credit Neuwirth for this is this idea of primary care as a coordinating platform. So right now, to Craig’s earlier point, primary care is kind of a dumping ground of like you're discharged from the hospital follow up with your primary care provider in three to seven days, oh, you need a referral to something, check with your primary care provider. So I think right now it's sort of this black box or, you know, amorphous dumping ground of thing. So this idea of a coordinating platform is can you appropriately have an easier entry for patients? But also like, hey, sounds like you need behavioral health therapy. Here's a, you know, here's an app for that, right? So some digital therapeutics, some ways that they can assist with that. So the patients still have a single place that they can go to, but it's not the primary care physician themselves that are having to do a one to one directing where that's happening. There's a whole team. So I think that's the idea of primary care is a coordinating platform that includes both people and the technology tools to do it. And then the difference between my doctor versus my care team. So for myself that we actually can transition to this a little bit. My current setup is I work with myself, a nurse practitioner and the medical assistant, and at any given time we are all working together to respond to patient concerns and patient messages. So I think that shift to my care team, primary care as a coordinating platform, are two big things that one, will ease the burden on the individual clinicians, but then two, also greatly improve access and kind of speed of answering for patients. And I think both of those, I don't think it'll fragment care too much. That's what people are worried about most. I think if it's done thoughtfully and again with a patient-centeredness in mind, I don't think it'll fragment here.
Dr. Jerome Pagani: Let's pull on that thread for a second because you're kind of describing the way you practice primary care as a team sport. So who's on your team, and how do you divide up the work amongst yourselves?
Dr. Matt Sakumoto: It flows, and one thing I'll highlight is that we call ourselves a pod, and I think that that's truly there. There are some places that have team-based care, but it's in layers. So things go through the patient navigator layer, and then it maybe makes that the nurse layer, and then it makes up to the clinician layer. Ours, we're jumping in and out and kind of blurring that line. We're more verticalized. So the team as it stands now is myself as an internal medicine physician, there's a nurse practitioner, as well as a medical assistant. Those are kind of the core team members. And then we have access to either a social worker or a registered dietitian for some of this health coaching, lifestyle change, and lifestyle management things that we do. But it's a team that the patient knows the names of all four, three or four members of the team. I think that part's really important for that continuity and to decrease that fragmentation, as I mentioned before.
Dr. Craig Joseph: So let me pull even more on that thread. So Matt, I'm going to pin you down. So if I'm your patient or your team's patient, I'm going to send a message to, I presume, probably you or the nurse practitioner, whoever's name I can find. And then, you know, how does that get the details? You know, how does that get addressed? Maybe it's a med refill question. Maybe it's, hey, I think I know I need to go see a specialist. Do you need to see me first? Kind of question. How have you successfully managed to kind of make that work? And are there, before I let you answer that question, are there policies and procedures that the mothership kind of looks over and wants to make sure that you're following? I'm quite older than you. And when I started practicing medicine, there was no mothership. And so I was it. And anything that I wanted to happen happened in my office. And so, you know, I certainly had, I'll just give you an example. As a pediatrician, I often got a phone call from a very worried parent that they left liquid amoxicillin out overnight. And, you know, you're supposed to refrigerate that, and it's kind of goes bad after leaving it out. And so my policy was, hey, I don't even want to hear about that. This is amoxicillin, call in, this is long before e-prescribing. Just call in the prescription for another, just call in another prescription. You know, write it down on a little message pad, and I'll sign it at the end of the day. But please don't ask me if it's okay. So are you allowed to do those kinds of things to get stuff done? And if so, how have you not been arrested yet?
Dr. Matt Sakumoto: Oh, this is recorded, right?
Dr. Craig Joseph: We are not recording. This is just between you and me. No one else will hear this.
Dr. Matt Sakumoto: No, we actually do play by the rules for the most part. I think the term we use a lot is tee it up for me, right? So there are things that, at the end of the day, the physician or clinician is ultimately responsible for signing and things are in or out of scope for different members of the team. But we're always checking with our legal team. But I mean, the difference between me having to type in, you know, computerized order entry for liquid amoxicillin of versus having the M.A. have it there for me to sign. I mean, would it be great if she had to sign it and send it? Yes. But having it there and me looking at it saying like, yep, that's right and sign, from speed of, again, speed of the patient getting what they need standpoint. And then my mental sanity standpoint is above and beyond again what the current status for most traditional primary care.
Dr. Craig Joseph: Alright So if I decide that I need to see a cardiologist, where does that go, to the NP or does that go to you, or is it just who's there that day?
Dr. Matt Sakumoto: Yeah. So that's kind of that's one way that we actually do a little bit of trickle-up things where certain things we have standard like reflex questions basically. So I guess for direct referrals, less of an issue, but have said I'll, I'll change a little bit. If a patient comes in with some kind of acute complaint cough my M.A. deals with it, like if this symptom, send the patient this question so you know that's within scope that's sort of a protocol that they can follow so by the time that it bubbles up to me I have a sense of like, okay, like, you know, they answered like the usual top five questions that I would ask anyway. And I'm able to kind of take that next step. And this is all without me having to be in the loop. So that's, again, one of those things where it's not like the M.A. is going to be sending in amoxicillin or my prescriptions, but they're able to kind of take those first steps or first three steps that I would have had to kind of do and cognitively think about. So they're sort of by protocol. We're gathering more information for patients.
Dr. Craig Joseph: And you always work with the same nurse practitioner and the same M.A. Is that the case?
Dr. Matt Sakumoto: Yeah, that continuity is key. I've seen places, and you can probably blur the lines a little bit, maybe like one physician to two A.P.Ps, you know, that's practice providers. But I wouldn't do those ratios any bigger than like three or five because then, at that point, you kind of start to lose that fidelity and that everyone has an individual practice style. I think that that helps preserve both, because we do so many handoffs, you know, for any kind of message that goes through. So like being able to almost it is like a team sport anticipating where someone, you know might be on the basketball court. So you can kind of pass them the ball or something. The football analogy, but being able to anticipate your teammate’s next move, I think, is so important. And again, to kind of provide this seamless communication with the patient, I think is super important.
Dr. Craig Joseph: Yeah. One of the things that Jerome and I talk about a lot is design and human-centered design. And I certainly we think about how the screen should look and, you know, what color should the alert be? But something as simple as maintaining continuity for your team is huge. And I think you just emphasized it that, you know, that ability to know the questions I'm going to ask before I ask them and it's not rocket science. It just takes time. And I'm amazed when we talk about medical assistants. These are generally folks with minimal or no formal training. I had a medical assistant that worked with me for five years, and she had been doing it long before I started practicing and I would sometimes laugh, again, this is all on paper, but, you know, I would walk into an exam room and I would say that Cheryl has already diagnosed your child with croup. And how do I know that Cheryl didn't say anything to me, but she did put a croup handout from one of the handouts that we had. There's a croup handout paper clipped to your chart, which gives me a sense of what she thinks is going to happen here. And I said, but don't worry, I'm going to I'm going to double-check and make sure I agree, she's only right about 95% of the time, which was true. And so, you know, again, she was able to very quickly kind of pick up on where I'm going to go and could predict what I needed before I had to ask for it. And there's only one way you get there, and that's through doing it over and over again. And it's not as efficient from an operations standpoint to have the same M.A. work with the same group, but it's often much easier to have people cross-trained, and you just go wherever you're needed that day. But boy, oh boy, it's a totally different experience for the patient and for the clinicians, I think.
Dr. Matt Sakumoto: And Craig, I want to kind of pull on one level deeper is, I love what you did with your M.A. in terms of you've built trust in your care team, right? That goes back to the patient. Say, I want to see my doctor versus I trust my care team by kind of saying like, yeah, she's part of the team. She's you know, she's just thinking ahead. She's just helping me out. That builds that trust for that next time that the patient calls in and says, like, I don't want to talk to the M.A, I want to talk to the doctor. It's like, let's be honest, the M.A. will be able to help you far more than I will be able to help you at this moment.
Dr. Craig Joseph: You know, Matt that's, I would love to take credit for that. I, you're absolutely right. And I absolutely did not even think about that. You know, I started practicing in the late nineties, and we weren't, at least where I was, no one was talking about team-based approaches. But you're 100% right. It sounds like I accidentally engendered that because Cheryl also was often the person who answered the phone, and she did get back to people, you know, if they called and, oftentimes, you know, via protocols that we never wrote down. But she knew, you know, there were certain things I need to see, you know, he's pulling at his ear like we're not we're never, ever calling in medicine for that. I need to see that. Well, he's got a, you know, a red rash, and it's just like Johnny over here. And he got a fever. And it sure sounds like Roseola. Well, we don't really need to see it. You know, she would do those kinds of triaging and it sounds like, in my brilliance, accidental brilliance, I encourage that. But that's a great point. And I think we need to be more thoughtful and, you know, direct about helping people, helping our patients to kind of learn to trust the folks around us if they can. But again, if this is someone who I've never met or I've worked with three times in the last year, I can't give that person my trust, and clearly, neither can my patient.
Dr. Jerome Pagani: Matt, one of your mottos is embrace the inbox. So what do you mean by that, and how have you avoided being absolutely pummeled by your colleagues when you show up at conferences?
Dr. Matt Sakumoto: I know I like to be spicy every so often, but I think for me, it goes back to the whole team based It's true team-based care, which we've then virtualized. And the main reason why we've done that is actually the amount of patient lives you can touch per date grows exponentially once you virtualize it, even if you're doing telephone calls, even if you're doing video visits, that's a one to one time that you're spending with the patient, which I love. And that's definitely those relationships. But if I'm titrating your blood pressure medicine or if I'm titrating your SSRI, I kind of need to know like how you're doing, are there any side effects? And we can go up, up, down, or keep it the same. So that embracing the inbox piece, one, and just better for patient care and better for patient access. And that's more fun when it's one, it's a team sport. Again, the learning curve was like a little bit tough when you I'll admit there were times where, like both myself and the nurse practitioner, double messaged patients luckily with the same answer. But, like we kind of learned that like, okay, how do you turn the investment into a team sport? But then that's when it's fun. Like that's when you learn how to pass the ball, how to anticipate each other's movements. And there's a little piece of almost going back to medical school for me, right? Like you're kind of relearning new steps, ways to ask questions with a history. So there's a little bit of that exploration piece, I think. But I also find fun. Well, I will say that one other reason that allows me to do this well is that my current structure is that all of my patients are value-based in some way, shape, or form. So either a commercial HMO or Medicare Advantage, Medicare, shared savings, things like that. So none of my incentives are let's try to put as many video visits back to back to back as possible. So that allows me time to think, learn and play in the investment. So that's the other reason is I get to live in a fantasy world that a lot of people don't. But that has really allowed, I think, like that growth that I've felt. And then I think and I will obviously try to give back and teach at least those learnings.
Dr. Jerome Pagani: So the inboxes are a great example of a pain point for both patients and physicians. Right? And so a lot of people feel like this moved the needle for patients and put a lot of burden on the physician side. And you know, we always use the analogy it's like somebody smoothed the wall on one side, and it looks all great. But if you just stick your head around, you can see the brick is sticking out on the other side. So, you know, aside from incentive structure and sort of this team-based approach, which you've already mentioned, are there other principles that you would think would apply to helping make that wall smooth on both sides?
Dr. Matt Sakumoto: Yeah, I think a lot of it is going back to that digital empathy thing is like, can we build patient empathy for what the doctors feel like on the other end, right? Or what the clinicians are feeling? And again, there was a great post by Death by Patient Portal out in JAMA. That was amazing. And so what briefly, what this physician did is he actually sent a mass message to all of his patients saying like, Hey, I'm getting crushed by like the amount of messages that are coming in. Just so you know, I'm getting, you know, hundreds of messages and it's really hard. And I'm also seeing patients all day and really kind of put himself out there. And what that did was like, I think patients just don't realize. So that sort of that that that empathy building, understanding what it's like on the other side of that wall, as you see, it's he showed the point bit. And I think that that resonated one really well with his patients. But I think the amazing thing, and this is kind of a cool part, I guess, about the electronic health record is all of his colleagues kind of saw that outgoing message, too. And they're like, oh, wow, like he did this and like this is so they kind of it sparked the conversation and decreased that isolation piece that happens in the In Basket. I guess actually taking it one step further kind of idea that I like it because it's a team sport, in basket time is very isolating. Because they're usually doing it either at home or like on your lunch breaks. I think that's also part of it too, is like, is there a way to make that more collaborative? But yeah, I think by him exposing be the pointy bit that really generated a ton of empathy from the patient side.
Dr. Craig Joseph: When I read that article, that editorial, I kind of was shocked that he would do that. And then shocked that I didn't think about that myself because it was a brilliant idea. And I don't think he intended for it to have any positive effects. He's just like, I got to tell you, patient panel, you're killing me over here, and I want to take care of you. But we need to figure something out together. It kind of reminds me, I was in a two-doctor practice for much of my professional career. Just two of us. And, you know, I talked to some dad in the middle of the night about something, and he'd brought the child in the next day to be seen. And I walk in, and he looks and maybe this was a dad thing versus a mom thing. But he said to me, “What are you doing here?” And I said, “Well, I work here. You know, this is my office.” He said, “Yeah, I know, but I talked to you. And at 3:00 this morning,” I'm like, “Yeah, I remember. I know.” He’s like, “Oh, but I assumed that if you were talking to people in the middle of the night, you weren't working the next day.” And I was like, “Oh, that's a great practice. Like, how do I do that? That would be awesome.” So I think with that one parent that I did probably get fewer, fewer unnecessary, you know, the newer parents don't know what's necessary or what's unnecessary, but at least they got the, you know, the respect of that dad. And I think that's what he may not have been going for. But the author got that. And people are still going to call you because it's appropriate for them to call you in the middle of the night. They're still going to message you via the patient portal because that's still appropriate for them to do. But at least be understanding that you are you do have another job and you're still maintaining, you know, seeing patients virtually and in person. And that's something important. So Matt, if you've been practicing long enough that you've seen or actually maybe even used paper charts with binders, or is this just something that you saw when you were an undergrad in the history of medicine class that you took?
Dr. Matt Sakumoto: Nope. During my internal medicine training, there was a binder you had and we would handwrite orders. I'm not that old, but like we were just at a hospital that hadn't fully adopted an electronic health record yet. So I've done, you know, transcriptions, transcriptions, get printed out, put input in the binders, turn the little knob at the nurse’s station. So, yes, I have seen the era of paper charts.
Dr. Craig Joseph: So those paper charts often had different sections in them. And I think you and I were talking once, and you noted that they almost all had a cardiology tab, but they maybe didn't have a nephrology tab or an endocrinology tab, but they always had, you know, certain core parts. And when we started moving from paper to the electronic world, we often just said, well, it works there, might as well work here. So I ask you, are there parts of the electronic health record or the way we practice medicine now in the US that you say, Well, this doesn't make any sense. I would have designed this differently. It’s an open question. I'll give you 30 seconds to answer.
Dr. Matt Sakumoto: Yeah. My biggest one, I think, is going to be on the virtual care side of things. Right? How do we take a clinic visit with a waiting room and a rooming process and all of these things and turn it into a Zoom call? I think there's ways to just virtualize that, right? So I think, again, I have a largely message-based practice, and sometimes I do video visits, but you can have this back and forth. It can happen over the course of multiple days. And then if you need to, you flip it into a video visit. So rather than trying to recreate a brick-and-mortar office experience, which like no one loves with waiting rooms and everything else, and then, trying to put it in a virtual context versus saying like, what are we actually trying to do here? What are the things that we're trying to accomplish just for strictly patient care? And how can we accomplish that without, again, having to recreate all of those steps of a traditional brick-and-mortar grooming process?
Dr. Craig Joseph: I have to say that I loved the traditional way. With the office, people came and they waited for me, and it was a great world. Matt, I'm not sure what's wrong with you, but yeah, that makes sense.
Dr. Jerome Pagani: Matt you live in Silicon Valley, or at least close enough that you wouldn't have to turn the page on one of the old Rand McNally Street Atlases. But there are a lot of startups and even some nontraditional health entrants that are identifying micro efficiencies. So parts of a health care delivery that they can optimize and deliver for less cost to the consumer. And these kinds of services, these micro-efficient services, are beginning to disintermediate traditional health systems. And those are those sets of services are things they rely on for revenue stream. So what are your thoughts about how health systems can compete and frankly, should they be even competing with those new entrants?
Dr. Matt Sakumoto: Good question. And it goes both to some care fragmentation as well. Right? If you're going to siphon off bits of care, how does that integrate in, and I think I can take the everyone can play nicely approach. So at a certain point, there are so many inefficiencies in medicine, and I do some health tech startups advising. I tell everybody it's like even if there's someone doing the same thing in your space, healthcare is so broken, like, go for it, do it. There's so many things that need fixing, but always thinking about how do you maintain that interoperability, like don't duplicate work. I think that's the thing where I think there's enough to go around, and again, enough inefficiency to go around. So I mean, I highly encourage like the smaller groups and people working in these different things because I think once you're outside of the big systems, you get that you look at it with eyes, right? You're not trying to recreate a fee-for-service billing stream that or people back in the office. You're thinking differently about it. So I'll take the Pollyanna view that both it's a both and answer.
Dr. Jerome Pagani: Yeah, both-and with the caveat that what we're thinking about is that the interoperability problem has been solved so that it reduces risks on the physician and patient side and also ensures that you're not getting duplicated efforts. Yeah, well, at the end of the podcast, we like to ask everybody this question, which is can you give us an example two or three examples of things that are so well designed that they and they could be outside of health care, but they're so well-designed that they bring you joy to interact with?
Dr. Matt Sakumoto: Yeah, I have my three things. For those that don't know, I love eating and cooking. So these are going to be definitely outside of the realm of health care. Underrated thing is the garlic press. Single-use tool only used minced garlic, and I thought, I don't need this. Like I have a knife. I have a cutting board. If I need to do a piece of garlic, fine. It's a Rincon garlic press. It has: one, presses the garlic well, two, easy to clean. And so, for both of those reasons, and there was a time I was like, oh, if I have to do like three garlic cloves, I'll only bring out the tool then. Now, even if it's just one, pull it out, do it, crush the garlic, and then wash tool, said the Rincon Garlic Press. Totally worth it.
Dr. Jerome Pagani: There are people that only use one garlic clove. I mean, is it someone from the Italian heritage?
Dr. Craig Joseph: This is insanity.
Dr. Jerome Pagani: Sorry. Sorry. Go ahead.
Dr. Matt Sakumoto: Because it's so that's one of the things which is a tool that seems so simple that I thought I didn't need it. And then now that it gets used daily. Yeah. Let's see the one other one actually, I'm not sure what the level of design is, but some but I will say so we were talking about this before we started the podcast. My dog that was barking is definitely something that is designed to bring joy. She is a 17-pound Cavapoo, this little white thing, but it is the level of interaction, the way that she looks at you, the way that she endears herself to you. That was like actually when you first asked the question to me, that was the first thing that popped into my mind was like, actually this dog is like built for bringing joy.
Dr. Craig Joseph: Wow. We yeah, I wasn't as surprised by the garlic press as I was by the dog, but it makes complete sense. Well, that's great, Matt thank you so much. It's been a pleasure talking with you today and learning about how we how you are trying to design a better healthcare system and both for you and for the patients that that you serve and your colleagues all around Silicon Valley and in the rest of the country. I think Silicon Valley's like 50% of the country. And then there's the other part, so thanks for joining us and keep on keeping on.
Dr. Matt Sakumoto: Thank you both. I had a great time.