Designing for Health: Shan Liu, MD

Intro:

You’re listening to in Network Nordics podcast series, where we explore health care and technology with experts from around the globe.

Hello and welcome to Designing for Health. I’m Nordic’s Chief Medical Officer, Dr. Craig Joseph.

My guest today is Dr. Shan Liu, an emergency physician at Mass General Hospital and a children’s book author. That combination sounds unlikely until you hear the story: her great-grandfather invented the first respirator mask during the 1910 Manchurian plague, and she co-wrote the book with her first-grade daughter during the early days of COVID, when mask debates were raging.

But we go well beyond the book. We talk about what the ED reveals about documentation burden, why the EHR note serves billing more than clinical thinking, and what implementation science tells us about the gap between knowing something works and actually getting people to do it.

A wide-ranging conversation and one worth your time.

Let’s plug in.

Craig Joseph MD, FAAP, FAMIA

Dr. Shan Liu, welcome to the podcast. How are you this morning?

Shan Liu, MD

I’m great. Thank you, Dr. Joseph. I’m delighted to be here. I’m really honored that you would invite me to. Thank you.

Craig Joseph MD, FAAP, FAMIA

It’s an honor for us to have any author. And so you’ve written a book and we’re going to we’re going to talk about that book, but we’re going to talk about all the other things that you do as well. Where do we find you?

Shan Liu, MD

I am in Brookline, Massachusetts, where I live, and I work at Massachusetts General Hospital. As an emergency physician.

Craig Joseph MD, FAAP, FAMIA

So let’s talk about that. I will call you an ER physician. Which I find annoys a lot of emergency medicine doctors because they’ve told me it’s more than a room, which I, I fully, I fully accept. Tell us about how you became an emergency medicine doctor in the Boston area. What was your life’s path? Is that something you’ve always wanted to do, or did you kind of stumble into it?

Shan Liu, MD

Actually, I had gone in to medical school saying I wanted to do family medicine or pediatrics, and then shadowed as part of our rotation for the first year of family medicine. Doctor. And it just the pace was really, you know, slower.

Craig Joseph MD, FAAP, FAMIA

Yeah.

Shan Liu, MD

And when you’re 22, I just was I just it didn’t really click. And my we had these small group tutorial sessions, which is how our medical school set up teaching. And my leader was Dana Stearns, Dr. Dana Stearns, who is now my colleague at MD. And he during the first session said, does anyone want to come shadowed me at MDH in the emergency department?

And I’m one of those people who, like, take people literally. And I’m like, sure, I’ll go. And so literally the second week of med school, I went and just loved it. I didn’t know anything about this specialty and the pace and the people and just the type of I use my Spanish and translate and so here I was, a first year med student, second week of school, and someone like you speak Spanish and the and I just loved the idea of serving the underserved and not caring about patients insurance and, and just wanting to be able to see everything that came through the door.

And a lot of people say that emergency doctors are adrenaline junkies. And I think when you’re 22, you’re like, you love that. And I would have to say we could talk about this later about career longevity is that I don’t need that stress anymore. But I, I have to kind of pivot to like other reasons to stay engaged in the job.

I wish I never had to see another gunshot wound. Right. Just for public health standpoint. But at the time when you’re 22 or 23, people love the action.

Craig Joseph MD, FAAP, FAMIA

Yeah, yeah. I, I did the opposite. So I actually went to medical school to become an emergency medicine doctor. Oh, and I was an EMT. And in college, my first real opportunity to be in the emergency room or emergency department, I was a it’s a beginning of my third year of school, and, I was yeah, I was like, oh, no, no, no.

It’s, you know, a bunch of, sitting around waiting for and nothing happening and then a bunch of lots of things happening. And I, I understand the desire for the for the fun. But, yeah, that was not for me. I kind of like the nice and smooth action in the clinic, which sometimes does get exciting, but I.

Yeah, not a fan. I did once, threatened to send a medical student home in the middle of the night when he said the key word. So. And this was up on the floors in the children’s hospital. And so, yeah, you don’t want to say the key word, I, I are you okay with the cute? I won’t even say it now just because I don’t want to jinx you in your next shift.

How do you feel about the Q word? And, I’ll spell it. You know for our audience. Q-U-I-E-T. You don’t want to say that word because.

Shan Liu, MD

It’s funny you say that.

Craig Joseph MD, FAAP, FAMIA

Are you okay with it?

Shan Liu, MD

Are you fine with it? I actually don’t think I have the power to actually change what happens when patients come in or not, and I. I feel like people, you know, it’s a lot of superstition, and I think it’s science.

Craig Joseph MD, FAAP, FAMIA

It is science. If you say the Q word, bad things happen. It is science. But let’s move on. I don’t want to argue with you about the facts, ma’am.

Shan Liu, MD

I would have to say if I, if I knew how to have parents hold children, I probably might be a it might have been a pediatrician. I just didn’t know how to get to teach parents how to hold the kids, to look in people’s ears. And I think that is was life changing when someone else was like, oh, this is how you do it? I was like, oh, I would have like much, you know, I would have enjoyed like seeing the ear and like, damaging the ear.

Craig Joseph MD, FAAP, FAMIA

But I think when you do it, you were having them hold up by one arm and, That’s bad. Yeah.

Shan Liu, MD

Yeah. No one taught me until, you know, years later, I was like.

Craig Joseph MD, FAAP, FAMIA

Oh, the shoulder? I must have just seen it once and, it just seemed, that’s how people do it. Yeah. There’s that’s the fun thing about pediatrics is looking at kid’s ears but no one’s listening to hear me talk about looking in kid’s ears. So let’s talk about your book, which I see over your left shoulder.

It’s not a typical book of someone that we have on the show for an emergency medicine physician. It’s not a tome about how to, discover septic shock a few minutes earlier than others. Tell us about the book. What’s it about? and we’ll certainly put a link to it in the show notes. And why did you write it and who is your coauthor? Everyone wants to know about your coauthor.

Shan Liu, MD

So my coauthor is my daughter. Kaili Lou and I did have to give her credit. So this was 2020 and obviously there was a pandemic. That was.

Craig Joseph MD, FAAP, FAMIA

I remember.

Shan Liu, MD

That changed our lives. And my daughter was in first grade and my son was, was three years old. And of course, everything had shut down daycare shut down, and elementary schools had shut down. And I was a horror sort of pretty horrible, you know, homeschool teacher because I just didn’t know how to teach, and I didn’t know how to make it engaging.

And I was just desperate to get some structure for my daughter since all they got was maybe two hour or like 1 or 2, like 1 or 2 hours. I at that age, they can’t really sit and be taught on zoom. But I finally found in a virtual writing course because I thought, you know, somebody with experience, you can at least sit there and entertain or give her some structure. I just needed some help.

Craig Joseph MD, FAAP, FAMIA

Yeah.

Shan Liu, MD

And one of so was this Boston University online course, and one of the assignments was to do a non nonfiction piece. And I at the time I’m an emergency doctor. And basically there were lots of debates as we know and remember about masks. And it turns out that my great grandfather, Wu Lien-teh, invented the first respirator mask.

Shan Liu, MD

And at that time, since there was all this debate about should you wear masks and what kind of masks and is it? There is no evidence to do this. I was just sort of in this frustrating role at work of people saying, well, there are no good data to wear a mask. And so this aligned with like when my, my daughter had to write this piece and I just looked at her, I was like, you know, you should learn about your great grandfather and his role in, in what’s going on.

And, and even, you know, as a, as a layperson, you’re like, should we be wearing masks? And so sort of this, you know, this opportunity, you know, for her to do this assignment also as a mom, to be like, you should just know about your ancestry. And so we dove into looking at this book that I have behind me, written by my great Aunt Wu Lien-teh’s daughter about him.

He did have an autobiography, but we kind of tackled the shorter, the shorter book that she had written. And basically we did this assignment. And during that summer at the same time, we just looked around and we were just reading because there was nothing else to do. There’s no activities. And so all we do is read and order things from Amazon and read and read.

And I just noticed, especially during this time of anti-Asian hate, hate things that were happening, that there were just very few books written about Asians. There are, I’m sorry, East Asians, I should say. And I just looked at my daughter and I just said, we just have to do this. We just have to write the story.

We have to get it out there. And I think it was this feeling of, I don’t have a lot of, you know, there’s not a lot I can control in my life right now, but maybe and I can’t control, you know, what adults feel about other races and they’re sort of embedded attitudes. But maybe I can change, you know, if I, if we start spreading the story of my kids, maybe they just might have a different outlook as they grow up.

And so is this. It was this interplay of, you know, Covid and masks and racism, and then also just being a mom and saying, like, I want you to grow up and be proud of a your racial heritage, but also your family ancestry. And that’s where this all started. So, so essentially wrote a draft and was and talked to some people. It was like, I don’t know where to start. I.

Craig Joseph MD, FAAP, FAMIA

Right.

Shan Liu, MD

I don’t know how to write a book, a children’s book, but just through various people in my lives, like opening doors, it ended up becoming a book that was published in 2023.

Craig Joseph MD, FAAP, FAMIA

I love it, I have it, I’ve read it. How long did it take? Like, we’re there? I’m just curious. Like, is this something that your daughter really engaged with and was interested in? From the beginning of the, you know, writing and then editing and then obviously there’s lots of, graphics and how did you kind of incorporate that into, at least at first, her schooling and then, maybe as school was getting back into session, into the, into the real world, I’m curious how involved she was. Did she get bored with it after a while, or was she intent on getting it all the way through?

Shan Liu, MD

Oh, that’s a good question. So I would say I really wanted to have it happen. And she sort of went along with, you know, along with mom, you know, but there were a lot of things that she would she would help me with it. And I would say it’s a it’s definitely a team effort. My sister was involved.

My husband played a huge part. He’s a he’s a writer, a reporter. And then just, you know, various people around me and then also Kylie. So she obviously was six and just, you know, not necessarily a writer, but she we would like, ask her questions and be like, what do you think about this title? Yeah. Can we talk about can we talk about death?

Can we talk about a play? Can we talk about like what’s really a dark thing? And I remember when I was sending this out to agents and we sent it out to the person that ultimately became my agent. And he’s like, you need to be more whimsical. And I said, I don’t I you know, you don’t know me, but I’m not whimsical. Just not my thing. And I don’t know how to make a story about, a plague.

Craig Joseph MD, FAAP, FAMIA

Whimsical. Whimsical. Yeah.

Shan Liu, MD

And so, you know, I had to, you know, try to throw things in there and ask. My daughter was like, I don’t know how to make this more interesting for you. So she was just like, sort of an expert that I would throw ideas at. And then she definitely was like, she’s much more a visual person. She helped me pick the illustrator.

Shan Liu, MD

She helped me, you know, with the title. And then she’d help me with, like looking at each of the proofs and she’s like, oh, you know, you messed up. You know, this. They messed up on this, on this detail, on, on what was the ambulance. And so that’s the sort of level that she was helping. Okay. And then the sort of the grand scheme, but she definitely like the original project of her writing the assignment was what?

You know, we spent a long time together writing that and doing the research. And so that’s sort of where it, where it originated.

Craig Joseph MD, FAAP, FAMIA

Did. So I’m assuming she had a lawyer and, you know, she hard to negotiate with like is were there she walk out on you a couple times or.

Shan Liu, MD

Oh yeah. She’s a hard bargain or. Yeah, she’s basically like either you give me all the royalties or not. And yeah, she says, you know what, mom? I think you just you wanted me for the marketing because I’m cute. And I was like, yeah, pretty much like.

Craig Joseph MD, FAAP, FAMIA

Hey, you know, I should talk to her, because that’s kind of what I do. That’s why I’m here. Yeah. Okay. Yeah, I’m just here because I’m cute. So that’s. So she and I, we would get along together. So you, I presume that you, you do readings and you kind of talk about the book, and, does she join you for any of these or. She does. All right.

Shan Liu, MD

Oh, yeah. And so we use her because she’s cute.

Craig Joseph MD, FAAP, FAMIA

Yeah, yeah. Love it. Love it to the max for sure. So how how’s that been? Like, how has the book been received when you go to bookstores or libraries or schools, do they kind of tell you like, oh, that was a tough time during the pandemic. And this would, this would have been or was helpful or have we all forgotten about the pandemic? And it doesn’t matter anyway because it’ll never happen again for sure.

Shan Liu, MD

Exactly. Right. Yes. Yeah. History never repeats itself. She has been great to have. I would have to say it’s funny to watch her over the years, because she’s now a middle schooler and there’s a lot more eye rolling. There are times when she’d get tired and obviously better, you know, she’d lie on the ground waiting for, like, the event to start. I’d be like, mom, why are we doing this again?

And I, I just love seeing her light up about this and really get out of her. I think, you know, normally she’s like, I it’s just hard for me to talk to strangers. She really lights up and is got confidence to do this in a way that I didn’t necessarily expect. So some of it’s been this awesome journey, just as a mom and daughter experience, to watch her grow and just put her in those positions because she’ll talk to reporters and they they’ll say, I think the one of the questions that I love is that she says, it’s like, well, so you’re, you know, a second or third grader and you’re a published author and she’ll say, yeah, I, I’ve always wanted to be an author since I was in kindergarten. And, and now I am. And she’s like, is it that that we’re just like and where everyone else is laughing and she’s like, what? It’s true.

Craig Joseph MD, FAAP, FAMIA

What is with these people?

Shan Liu, MD

I know that’s like, you know, check.

Craig Joseph MD, FAAP, FAMIA

I love that. All right. So obviously the mask became not only a medical instrument that we still use and in health care all the time, of course, in the operating room and whenever we’re sick or whenever around us. And an ill patient. Have you had any interesting conversations that you’re that you can share that people have kind of opened up to you because of the, of the book or the or the book tour? Like what’s I guess what I’m asking is what’s the sense? What’s the sense out there in the world about the face mask?

Shan Liu, MD

I would say no one loves wearing a mask especially, but I think the surgical mask is a lot easier to tolerate. I, you know, having had to wear a mask for a long time in the in the hospital, don’t love wearing them. Nobody loves wearing this thing that like, feels like you can’t you can’t breathe as easily as if you don’t.

So I, for one, am the first to say we don’t love wearing them. But I at that time, it’s like you either wear this or, you know, you could be exposed to this deadly virus, but we’re all relieved that only occasionally do you have to wear them. Now, it’s been interesting to give the talk at various places.

Most of the time it’s been the East Coast, West coast. I did share this with a group from a very varied background, and this woman was from Montana, and I wrote the story of like my reflection about why I wrote the book, and she was in tears. She said, you know, I just had no idea that that’s what you experienced.

You know, she’s in the middle of rural Montana. She’s like, I didn’t know why I had to wear it when, like the next neighbor I had with like five miles away. And I get that, I get that that it doesn’t make as much sense if you’re in rural Montana. But she also just didn’t have any idea what the Asian experience was like at that time.

And she just was she just was really moved to tears. And she I just didn’t know. And that’s what’s great about sharing the story for some people that they just they would never know. They would never know that in New York or like in different places, there were hate crimes that were happening because it’s just not part of their daily interactions or stories.

And so it’s been meaningful to share that, that we all have different experiences, lived experiences, obviously, and that she welcomed it. She didn’t say that you’re wrong for having had this policy that but she just didn’t. People just didn’t understand, you know? Yeah, it’s like locally you didn’t have that much Covid.

Craig Joseph MD, FAAP, FAMIA

I sometimes see people even now driving their in their car with the windows up, and I see a, a face mask on and I’m like, I’m not sure who you’re who you’re protecting there. I can’t imagine there are there are folks who reasonably say like, yeah, I’m, I’m by myself or my closest neighbors five miles away. Why would I need a mask?

And the answer, of course, is you. Well, you don’t when your closest neighbor is five miles away. However, if you’re going to the grocery store, then your closest neighbor is now less than five feet away. And that that does change things. Based on your research, is there a difference between, I think, maybe specifically East Asian culture and other cultures where it’s easier to wear a mask?

I just recall even long before the pandemic when you’d go to airports, I would see, you know, certain groups of people with masks on, which, again, clearly is going to make them much less susceptible to getting a common cold. But, just seem to be part of the culture, even though there probably wasn’t science to support that, you really need to do that unless you’re interested in decreasing the risk of getting, cold or the flu, which a lot of us now are interested in doing, that is there is there a cultural difference that that that, you know, makes it easier or more difficult?

Shan Liu, MD

Yeah, a great question. So there’s a medical sociologist, Chris Harris, who’s in Scotland, who I met a couple of years ago who studied Doctor Wu and basically has this idea that, you know, Asia really pivoted to the mask quickly, stemming from my great grandfather’s work, because at that time, China was seen as like the sick country of the world.

It had opium issues. It had just a lot of diseases. And my great grandfather, who was trained in Cambridge, England, kind of came in and was like used his Western, for lack of a better word, training to come up with a mask. Yeah. And he was recruited to Harbin, northern China, where this, this, plague was spreading and pretty much everyone died.

And so you go from this, like, deadly disease to in for months. The mask, among other things, really stopped this, the transmission of this disease. And so when my great grandfather instilled that everyone had to wear these masks and then transmission stopped and then for months, like, you know, people, 60,000 people died. And then to end it, in four months, people were like, there is something about this, and we’re going to wear it.

And it became this idea of, I believe in germ theory. I believe in protecting my neighbor. And I think what to your question of what’s different culturally, people wear the mask because they think of it as well. This is the moment that China went from sort of mixing eastern medicine to also including Western medicine. And so it’s like we believe in germ theory, we believe in modern science.

On top of I think the idea is like we protect others. And so the mask has always been in and a lot more in Asia of like it’s a sign that like, if I have a cold, I don’t want to get you sick, Doctor Joseph. I don’t want to get you. I care about you. It is less the government mandating there is that too.

I would have to say, obviously in China, but there is. There is just also the sense of on a, on a person to person level. And it’s sort of a sign of respect in my, in my understanding, rather than I have to do this for just to protect me. So it has a little bit. And then also in Asia people wear it because of the pollution and it’s.

Craig Joseph MD, FAAP, FAMIA

Oh, I hadn’t thought about that. Yeah. So it’s yeah.

Shan Liu, MD

Well to mix. Yeah.

Craig Joseph MD, FAAP, FAMIA

It’s not I well I love the idea of, of, you know, I’m doing this to protect me a little bit, but to protect the community. Yes. And there, there are many things that in, in public health where we’re asking people to do something to protect not just themselves but the people around them, which, of course, is your family, your friends and people you’ve never met before.

I hadn’t thought about the pollution aspect of it. All right. Interesting. Well, let me let me pivot a little bit to some of your other writings. So we’ve got the important thing, which is the writing with your daughter. But I don’t think your daughter was involved in a study from 2020 about Co-work. I’m sorry about teamwork in the emergency department.

And so you coauthored a review that talked about teamwork and communicating and actually showed that a safety culture in the emergency department actually improved the care and made it safer for everyone involved. And it seems like that’s kind of common sense. But I think it’s a interesting to talk about from an evidence of viewpoint. And B, I’m interested in knowing, well, how do we take those lessons learned and apply them in, in larger teams. So outside of the emergency department. So yeah, tons of questions there. Let’s just talk about the study. And what do you think were the most important things that you learned?

Shan Liu, MD

I never wanted to go to those talks about, you know, what you call soft skills like leadership, communication. I was like, I know how to do that. Like, it’s easy, isn’t it easy to, like, talk to a patient about bad news? Like you just tell them, yeah, yeah. You have this is a bad and this is what you should do.

And it is so much harder. It’s probably harder than actually coming up with the hard intervention of diagnosis or therapy. It’s like the science and it. So that that’s why a study done, in a, in a randomized trial is so different than when you implement it. And like that’s why implementation science has become more important because you can have all the data in the world.

I mean, clearly masks work, right? Clearly masks work to stop transmission. But it doesn’t make sense to force everyone to do it in all situations. If people are not going to do it, like to mandate it. If there is such resistance that like people revolt around it. So yeah, there is just as much emphasis about how you communicate the messaging and we all know that.

So if I if one boss, if one executive tells you should do this, everyone you know, there are people who follow. And then if another person can say the same message, but people just don’t follow. And I have come to realize that all of those skills are really important. And I think as a parent and as a daughter, how you deliver it and how you, how you build community is so important.

But it’s so much harder, I think, because it’s a little bit less obvious how to do that, because it’s based on the individual who’s involved. But there is there is a way to do it. And I think, I don’t know if leadership, all leaders understand how to create that a culture of because I think the same thing and what we’re talking about is for Swat, like, if you have the messenger is like, I want to create this culture in our department or in our hospital that we all care about each other and we’re all trying to do the same thing.

It’s different than like, you absolutely have to do this. Like you absolutely have to do this now. Times are hard. Health care is we’re cutting costs everywhere, can be delivered in such different ways, I think. And you can. And people in health care, we’re all trying to do the right thing for our patients. But sometimes there’s just like incentives I get that are in conflict. And just the sort of the messaging that is that is just as important, I think, for, for you to create followers.

Craig Joseph MD, FAAP, FAMIA

I’d love to follow up on, on that term that you used implementation science because I think like at least ten years ago, I had never heard of such a thing. And to your point, it seems very simple. Like we have a study and it says if you take this medicine that you’re statistically likely to get better. So duh, take the medicine.

And my hands are, I’m done with this. And that idea of, of, of implementing this new policy or this new idea that this, this is a helpful medicine can really make or break your the success. And we see it from technology to implementation of, of new research. So we’re in one part of the country or in one hospital system or one clinic.

Boy they’re really doing great with this. And, and the maybe even across the street, they’re not. And the difference often can be the physician or the nurse or the environment that’s, that’s been created. And, and people study that. Now when we call it implementation science. And it probably gets hardly any of the publicity that it that it should because as you’ve noted, and as you’re kind of your research shows, if you don’t have those soft skills, you’re not going to succeed.

So how do you so in your emergency departments, you know, how do you foster that culture, that safety culture of both? When I say safety, I’m talking, of course, about the patients, but I’m also talking about your colleagues and everyone that works in the emergency department. How do you get them to think of themselves as a member of the team? Are there these just trust exercises where I fall backwards and hope someone catches me? Is it is it? If it’s that easy, tell me please.

Shan Liu, MD

Well, I think there are official things and unofficial things. I think hospitals have pivoted more. You know, they’ve been using things like wellness divisions and departments, and some people push against that. And say, if you give me a an exercise pass, it doesn’t placate the fact that it’s so corporate. Now everyone needs and interprets what wellness is differently.

Some people are like, I just need you to give me a raise, and some people just need you to like create a message that I can follow. And other people are like, I just need you to give me time with my family and rest. And not for it not to be crowded. So I think we have to understand that everyone needs different things in terms of public health and messaging and change in leadership.

You can foster that. We all are in this together and that we care. And I’m in the trenches with you because I think that’s really important for me as a person. I want to see a leader who’s like, in the trenches with me, who’s taking a, you know, pay cut. If we’re all taking pay cuts, like everyone’s taking it.

So we’re all in this boat together. So and then it’s also fostering community on, on micro level. So having small mentoring groups or department groups, I don’t have an official position on a department, but some of the we’ve had karaoke and there’s nothing more like bonding than when everyone has to be embarrassed and sing a song, you know, but things like that, like those are sort of it’s not necessarily like the data shows that we should do this with sepsis, but it translates into like building community ties.

And people would say, like, if you want to have good inner departmental relations, there’s nothing better than actually having people like we used to rotate with the surgeons on the same team in the emergency department for 24 hours. And those people I still, you know, years and years later because surgery and emergency medicine often, you know, butted heads, but you put us in the department together as a team.

I still send Christmas cards, you know, to one of my colleagues. And we were in it together 24 hours a day. Every other day for a month, and she invite me to her wedding. So those kind of ties, it sort of, you know, when you’re in the Army or at or when you’re in the trenches together, you inevitably build bonds.

And I think people have to understand that there are efficiencies, you know, that need to be in place from an economic standpoint, but not sometimes at the cost of having those soft skills and ties and relationships. Because I think as you corporate, you know, corporatized medicine, there are definitely things that are better, you know, obviously, but they’re also things that can’t be lost in that mix of and you have to still treat community and trust on smaller levels.

Craig Joseph MD, FAAP, FAMIA

I think you mentioned the Army and that kind of fostering that, that camaraderie. And I’ve, I’ve heard some speakers lately talk about their desire for, for the US to institute some sort of mandatory public service for private, you know, probably for like high school kids graduating, maybe before they go to college. One of those could be certainly military service, but others, there’s lots of nonmilitary things that one could do.

And I think a lot of that seems to or the success that people have seen is when you’re really taking people from all over the country, as you mentioned, meaning someone who live five miles away from the next person as opposed to five feet away from the next person in New York City. And when you put those folks together, even for a short amount of time, like a year, they understand things and are much more tolerant of people because, as she said, is that yeah.

Woman that said, like, I had no idea that this was a problem, that there was, you know, there was Asian hate. That was a foreign idea to her that that existed. And, boy, when you spend time with, even with, even with surgeons, that they can actually be human. I still even I heard you say it, but I still find it a foreign idea that, you know, you can be friendly with surgery.

I’m joking. But, yeah, that’s a that’s a great, it’s a great concept. And I, you know, I think of that as design. You’re like, you are does when you create those programs and you have mandatory karaoke and you make the emergency medicine, the emergency medicine doctors, really spend a lot of time with their surgeon colleagues who maybe outside of health care, it doesn’t seem obvious, but oftentimes what the surgeon wants to do and what the emergency medicine wants to, doctor wants to do might be different.

And, and they have to kind of, figure out what’s really best for the patient from the, from the, more macro level. And so that’s all pretty interesting. Let’s, let’s keep on this idea of design. You spend your clinical time in the emergency department. Are there things in the emergency you’re in the kind of concept of emergency medicine that if you were starting from scratch, you might add, or even maybe more fun, are there things that are in your day to day in one of your routine shifts that you just wish you could remove?

So they’re not be, a waiting room? Although I suspect that’s kind of an impossibility in an outpatient setting. We try to get rid of the waiting rooms, but what are some of the things that you’d love to add or remove from your typical shift?

Shan Liu, MD

Well, I think there’s always this note taking or spending on the EMR, which I understand. I think the EMR is important for many reasons, obviously for me to record what I’m thinking, but it has become so many boxes in order to get funded, to get reimbursed or to bill that, as you know. Right. The review systems is burdensome and it has changed for emergency medicine in terms of this, but they replaced it with other boxes to fill.

Like did you review the records from something from the last, from another visit that wasn’t emergency medicine. So those are sort of not ideal, right. Sure. Like I just actually if they came in last night, I’m going to read what happened last night. And I don’t need to know what happened five years ago when it. But I don’t get Bill.

I don’t get to get reimbursement for clicking a box that said what had happened last night, even though the intention is to compensate me for looking at an old record. So that would be great if the record sort of reflected what was, what was useful and how I spent my time. That would be great if it really aligned with.

And then they tried to make it better. So they tried to say, we’re going to allow you to, to bill for social determinants of health. So that’s a step in the right direction. I think they missed in terms of saying I can’t read my colleagues note from last night and get someone obviously, yes, to get similar sort of credit for that.

It’s like it did. I look at the record before. So now I’m searching. Two years ago for the dermatology appointment because it’s not an M, it’s not emergency medicine. No. So that I think is would be I would love that to change. But in general I think sir writing my note. So I think the assessment and plan makes sense.

Like I should write down why I did this and this and this. And so I’m not saying we don’t need the EMR at all. Obviously we do. I think it just should boil down to like what we really need. And as you know, when you read through like the essay, you really just want to get to the bottom line, like, what did you do?

And why. So I think if it could be more efficient and now I’m sure if everyone who has used these medical record numbers that are digital, it’s great, it’s convenient, but it’s really hard to sift through and say what you know, how do you create this story that’s actually helpful? So I think making it efficient and not making it as much this like the only way we can get reimbursed would be lovely.

Craig Joseph MD, FAAP, FAMIA

You said a magic word to me, which was story, because that’s really what you’re trying to tell, right? And no matter what you do, whether you write a book which is a story or a note about a patient, you know, you want to get their story in there. And that’s one of the things that I think we’ve missed going from paper to digital.

There was, you know, when you were papers, this blank sheet of paper, and, you know, you really had an opportunity to kind of try to get that story in there and then sometimes clicking boxes, just not the only way to. And I think a lot of us are moving to ambient scribes, and I’m not sure if you’ve had any experience with that in the emergency department yet, but, you know, being able to to get that story to what’s really going on and then being able to summarize it very quickly.

To your point, most physicians at especially when I was in private practice and would send a patient out for to see a specialist, I would instantly go, if it’s a three page note that I get back a three page letter, I’m just going to the page three almost daily. Assessment of plant. Right. What did you think? What are you doing or what do you need me to do to help this patient and so that’s the assessment of plan.

That’s really what I need. And oftentimes that story can kind of be figured out by looking at your assessment plan. If it’s well written. Have you all used have you started personally using any ambient scribes in the emergency department?

Shan Liu, MD

It’s funny you asked that they were just talking about that at faculty meeting on Wednesday. So two days ago and I, they everyone was talking about how they’re using it and how to how to decrease the note burden on the residents. And why are we duplicating effort? I to answer your question, no, it’s on my to do list now after that meeting because I’m just a slow adopt adapter.

Craig Joseph MD, FAAP, FAMIA

I just you’re one of those say I am.

Shan Liu, MD

it’s hard to, you know, I kind of like my flow and it’s like, I’ve done that flow for I’ve used that flow for, you know, a long time. And it’s hard to, you know, I, I document more than I should, but only because that has seemed to that’s my most efficient way of doing it for myself. But I need to change. I need to use new things.

Craig Joseph MD, FAAP, FAMIA

You know, I’m a I’m a believer in if it’s not broken, no need to fix it. If it works for you, you know, that’s fine. I’ve met a lot of physicians, mostly internists, not emergency medicine docs who say, listen, writing the no like handwriting it type hand typing it. Really thinking about it helps me figure out what’s going on with this very complicated patient.

And if you took that away from me, if you force me to use to have a scribe, either a human or a computer, do that. I’m afraid that some of the deep thinking that I want to do, I wouldn’t do or I would have thought I did it, but I if I’m not actually composing this thing from the beginning to the end, that there’s a missed opportunity there. So I you’re not alone.

Shan Liu, MD

Yes. I, I agree that the I want that assessment and plan to be to be a time where I’m really actually thinking about what’s in front of, you know, about what’s going on in terms of this case and the patient and what just it just helps me think through things rather than just leaving it up to the ambient I to come up a summary.

Craig Joseph MD, FAAP, FAMIA

And that’s fine. And you really do to kind of leverage whether it’s the whether the scribe again, is human or not, you have to say things that so that the scribe can hear them, that you would normally have to say out loud if you were just thinking because you want it to be kind of picked up and, and incorporated into, into the notes.

So yeah, no, no easy answers for sure. I’d love to keep talking. But we are we have run out of time. As you may know, I, we always like to ask the same question of all of our guests, which is, is there something that’s so well designed in your life that it brings you joy whenever you interact with it? So is there is there something like that? Doctor Lou?

Shan Liu, MD

Yes, it is my Instapot so.

I love it.

Shan Liu, MD

My Instapot someone gave it to me for my wedding years ago, and it sat in the closet for a long time because I thought, it’s so bulky, what do I need? This I have a slow cooker. I have a rice cooker. Have a steamer. And then I brought it out and I was like, it’s all in one. And it was like, I can leave and just let it do its thing. I can like go pick up my kids and come back and it’s not going to burn down the house, and I can do all of that in there, you know, like it’s amazing.

Okay. In fact, it’s a it’s, so I think Instapot or sorry, pressure cookers were sort of dangerous before I, I was I always worried it was just going to blow up and, you know, that would come off. But this is it is like an iPhone really. Like it’s largely you could just do, you know, there’s only a couple of buttons to hit and then that’s it.

You don’t have to read the instructions. You just kind of made you do right, like you have to in terms of like the pressure valve or not. But aside from that and timing it, it’s so sad that it’s so successful that it went out of, you know, that it’s bankrupt because people don’t have to buy more of them.

They just buy one and it’s going to last. So it’s so well designed that nobody bought another one.

Craig Joseph MD, FAAP, FAMIA

Yeah.

Shan Liu, MD

And that that is what’s sad because it’s that great, great invention.

Craig Joseph MD, FAAP, FAMIA

Yeah. So I hear what you’re saying. And so what you’re asking for are, are more things that will die after 2 or 3 years so that you can buy them again. I know it’s funny that you mentioned it, that, I think, Apple is is finding the same thing with, with the iPhone like you reference the iPhone.

A lot of people are like, it’s pretty good. I don’t really know why I need to get a new one, and it lasts a long time. They’re the difference between one year and the next is getting smaller and smaller. Right. And so yeah, well, that’s I, I think that’s great. It’s a well-designed tool. You made me think of, of, I think his name was Alton Brown, the chef that had a TV show.

And one of the things that he was big on was he, he refused to buy or recommend a single use instrument or tool. Right. Like it? It needed to do a bunch of different things. And like I said, this does a bunch of different things and so I love it. Alton Brown also would love it. So congrats to you.

All right. Well, Doctor Sean Woo, really appreciate your time. And as I mentioned, we will put a link to the book that you and your famous coauthor daughter, wrote, and I encourage everyone to pick it up. It’s fun. And I think it serves a great purpose. So thanks again for being on the show with us today.

Shan Liu, MD

Thank you, Doctor Joseph, and thank you for all you do. And thank you for your amazing book. I really love that you’re really focusing on putting the patient in the center of all this technology and future of health care. So thank you for the invitation and thank you for the conversation. And I really appreciate it.

Craig Joseph MD, FAAP, FAMIA

And you’re most welcome. You almost lost the $20 I promised you if you did say something nice about the book. But you got it in right at the end, so congratulations. All right. Thanks again.

Shan Liu, MD

Thank you.

Outro:

Thanks for tuning in. We hope you enjoyed today’s episode. For more on Shan Liu, follow her on LinkedIn. If you’re interested in learning more about her book, we’ve put a link to it in the show notes.

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