Reducing the Distance Between Patient and Provider

Mitch: You are listening to The Scope, on the floor of the AAMC Learn Serve Lead 2022 conference, where we are having conversations with the movers and shakers in academic medicine who are looking to kind of change the way we do things from the ground up.

And today, we're going to be having a couple of people on to kind of talk to us about how we can kind of maybe change the health of the nation if we change the way we educate in medicine. And the idea that if we can expand access to people who have typically not had it, the way we do it is by reaching them where they are already at.

To discuss this, we are joined by Dr. Pedro Greer. He is the Dean of the Roseman University College of Medicine, as well as Dr. Lu Brewster, who is the Senior Executive Dean for Community Health Innovation at Roseman University College of Medicine, as well as Dr. Jose Rodriguez, who will be leading the conversation today, who is the Associate Vice President of Equity, Diversity, and Inclusion for University of Utah Health.

So let's start with you, Dr. Rodriguez. How do we change the health of the nation by changing medical education?

Dr. Rodriguez: Well, I am very lucky to be here with Dr. Greer and Dr. Brewster. All three of us lived in Miami, and previously, before being at Roseman, they were at FIU College of Medicine. And so what I'd like to hear about is some of the stuff that you're doing at Roseman and the stuff that you did in Miami to kind of address this issue of bringing health to the people.

Dr. Greer: Well, actually, let me start off. The architect of what we're going to be talking about is Dr. Lu Brewster, and the question that was asked was, "How do we get to the poorest patient before they show up at the clinic?" And so that was put in front of us.

And the answer to something like that does not come from MDs. It comes from a collection of individuals that actually understand community and understand society. We understand science and disease, but we need individuals that actually this is where not only they're trained, but where their mission lies. And with that, I'm going to stop talking and I'm going to hand it over to Lu.

Dr. Brewster: Well, I would say one of the big things is that we do need MDs. We need MDs to change the definition of what is leadership in medicine. And that means, like Dr. Greer was saying, that we have to empower all members of the interprofessional team to play a valuable role in addressing some of the change that's needed.

The reality is that medicine and health have become a lot more social and a lot more reliant on the activities and the context that people live in every day. And those are things that sadly are outside of the purview and the expertise many times of clinicians.

That does not mean that clinicians are marginalized in that process. It just means that there are others that they can draw expertise from. No different than their reliance on data analytics and data scientists or individuals who have expertise in nursing or any other skill set needed.

But at the core of it is reducing the distance between the patient and their provider. When you get closer to the people that you are supposed to serve, exciting things, great things, and spectacular things occur. And so by having physicians as they're training visit the homes of the individuals that they're caring for, you now have a shared existence with them, even for a brief time.

If they have an infestation in their home, you now are in that infestation. If they have a leaky roof, the water is now dripping on your head as well. And so you have a heightened motivation to do something about it when you know that you have to go back to that home in a month's time.

And so that's really what Joe kind of challenged all of us to do, was to just try to get medical students to learn empathy through lived experiences.

Dr. Greer: And let me just add something on there too. This is going up against established academic medicine, which just to put it very clearly, structurally we are racist, we are sexist, we are xenophobic, and we are elitist. The average income of an American medical student's family in 2020 was two to three times that of the national average. But on graduation, we are required to take care of an entire population without really understanding it.

And one of the most amazing things that Lu has done . . . Because when we take the student into the household, you change the power differential. You're no longer coming to the ivory tower. You're entering somebody's home. And Lu made a requirement that the student, the medical student, was never allowed to ask, "How do you feel?" The question had to be, "What is your most urgent need?"

And so all of a sudden the student now understands the reality. The student then understands also that the doctor is not always the king or the queen. The doctor sometimes has to be just a member of the team and sometimes probably the member that can contribute the least. You have to admit that, and that's the truth.

Dr. Brewster: That's a humble approach to care.

Dr. Rodriguez: And that's wonderful. Now, if I remember correctly, this program that you guys ran wasn't just once a month for one year?

Dr. Brewster: No.

Dr. Rodriguez: It was for . . .

Dr. Brewster:All four years.

Dr. Rodriguez: All four years.

Dr. Brewster: And it could be . . . it was a minimum of one visit per month. We had some students who were doing visits multiple times a month. But also keep in mind we had a full-time team of lay health workers who were recruiting, supporting the students along the way.

So even when visits weren't being performed by the students, we had enough commitment to the community to hire a team, that quite honestly has never really had a role in medical education, to manage and support the students when they are taking exams and doing the things that students have to do. The household is not left in a lurch. They actually still have support. They still have someone to contact them.

And the beauty of it is that we preferentially hired individuals from the community that we were doing home visits in, and we looked for individuals who didn't have a college degree.

Because the reality is this: Everything that we did, we embedded the same philosophy in. We didn't want to be the medical school that was good at helping students and good at creating good experiences for students, but then neglecting and avoiding the societal ails that were broadly impacting the work that we were doing.

When we go in these communities, people need jobs, so why not hire them? Oftentimes medical schools don't even purchase . . . their procurement excludes these communities. They have things to sell. We would buy from those communities. We would take individuals who didn't have a college degree, bring them in, and get them college degrees.

Dr. Greer: Over half of those ended up with college degrees. One, by the way . . .

Dr. Rodriguez: That's spectacular.

Dr. Greer: . . . is now getting her Ph.D. in Policy Analysis at the RAND Corporation.

Dr. Rodriguez: And these are community health workers you're talking about?

Dr. Brewster: These are community health workers, but we didn't call them community health workers. Just to tell you how the system is so screwed up . . . Because if we called them community health workers without the certification from the state, then they wouldn't be recognized. So we purposefully called them outreach workers, neglected to do the outreach training.

But you know what? That was a benefit. They did us a favor, because by creating our own training modules, we were able to put people on a path. What we learned was the retention for community health workers in other programs was terrible, but we kept our people. Why? Because we didn't train them with the expectation that they were going to do this job the rest of their lives.

We gave them transferable skills, got them degrees so that they can enjoy and pursue the careers they wanted to pursue. You learn by serving and then you go on and you enjoy the prosperity that everyone else has.

Dr. Greer: And the other lesson that became very important is called Social Accountability, to be responsible for what is going on in your community. It's by looking at it not from, "How do I train my medical student?" but, "How do I prepare the future physician to really serve our country and improve the health of our nation?"

For example, if it was just the student, we wouldn't care about the community. The community sees that that becomes vitally important.

And some of the students upon graduation, the saddest part was they had to leave their family. But the other aspect from a medical education perspective, what other course gives you four years of longitudinal care of the same household? Which is what you're going to be doing in a true medical practice.

I'm a gastroenterologist/hepatologist, and students are always shocked that when they ask, "What is your most urgent need?" medical never comes up.

Dr. Rodriguez: Interesting.

Dr. Greer: And I've been in practice over 45 years, and as a gastroenterologist asking the question, nobody has ever said colonoscopy is their most urgent need.

Dr. Brewster: Because at the end of the day, people want to address their basic needs first.

Dr. Rodriguez: Absolutely.

Dr. Brewster: "I want to feed my family first." Right? And we've all know the story of people who will give up everything to make sure their children are fed.

Dr. Rodriguez: Absolutely.

Dr. Brewster: They will limp into an emergency department after they fed their family. And so what we did was we made a conscious effort to not go to healthcare providers to recruit households. We went to non-health-providing non-profits that were seeing these individuals first, trained them on how to identify them, and then referred them to us.

By the last number I saw to date, we've serviced 14,000 households in South Florida, okay? Fourteen thousand.

Dr. Rodriguez: Fourteen thousand?

Dr. Brewster: Fourteen thousand uninsured, low-income households in . . . And we're not even there anymore. So now we're bringing this to Southern Nevada, to Las Vegas, implementing this. We've already started it. In South Florida, it was called Neighborhood Help. In Las Vegas, we call it Genesis.

Dr. Greer: And we've taken it a step further. Tell them about the cars.

Dr. Brewster: Oh, it's incredible. So now always being responsive, the first intervention is always right outside our office door. So one of the things that Dr. Greer gave us the ability to do was to purchase electric vehicles for our staff. And that's because I didn't want the burden on their cars, right? I didn't want you to have to own a vehicle to work for me, right? And so now you can go and serve your community, work for us, and drive the vehicles that we have.

But the second part to that is that low-income communities are always the last to receive innovation. I'm amazed that there were no electric vehicle chargers in these communities before we got there. But now since we're doing it, we can basically say, "If you want these services in your community, then you've got to put chargers, because my cars need to be charged so that we can continue to do the work." So now there's a backend motivation or incentive to bring technology to these communities.

The next element, our goal is to create what's called Genesis Zone, six of them. Six free Wi-Fi-enabled areas that . . . Yes, every household that is in our area will have free Wi-Fi, and being able to provide care digitally and offline, high-touch services in their home.

Dr. Rodriguez: This is a spectacular revolution.

Dr. Greer: And not only that, what comes out really important for the students is they do a lot of reflective writings and narrative writings. Now, why does that become important? Because if we're training the future workforce to be leaders, if they can't tell a story, they cannot make a change.

Dr. Brewster: Exactly. Because what does Joe tell me? "Facts tell, stories sell."

Dr. Rodriguez: All right. Can I steal that? Because I'm putting that in my leadership . . .

Dr. Brewster: Joe told me that all the time. "Facts tell, stories sell." And at the end of the day, we can dress it up all we want, but you have to sell healthcare to individuals in this day and age. There are too many competing narratives. There are too many competing priorities. You have to sell it. You have to find a way to make people do something they don't want to do and love it. That's true medical leadership, finding a way to get them to do something they don't want to do and love.

We have a mascot for Genesis. It's called the Apple Cone. And so the reason we have it is that people want ice cream, but we need them to have apples. So we have an actual design of an apple cone. I'll send it to you. It's an apple on top of an ice cream cone. And that's to remind the staff, remind the community that we're going to meet you where you are. I know you want ice cream, but we want you to have an apple. So how would we find a middle ground?

Dr. Greer: And we told them we have enough patients for the dental school.

Dr. Rodriguez: What an incredible story. This is the kind of thing that needs to happen everywhere.

Dr. Brewster: Exactly.

Dr. Rodriguez: And bringing this to the community. It's revolutionary what you've guys have done in both places that you've been. Having a medical student . . . having one class for four years is miraculous to begin with. Then to have them have a relationship with families for four years? They're people who won't stay in the same job for four years in their entire career, and you've given them a gift for their entire career.

Dr. Brewster: And can I give you some retention rates?

Dr. Rodriguez: Oh, please share.

Dr. Brewster: So, in South Florida, our 12-month retention rate for households was 83%.

Dr. Rodriguez: Oh my gosh.

Dr. Greer: Unfunded.

Dr. Brewster: Our 24-month retention rate was 77%. That's with no incentives for anyone. Not the organizations, not the families, no one. No money is exchanged anywhere in that system.

Dr. Greer: Let me tell you how successful . . . We were in all parts of South Florida, south to north. But in the northern part of the county when we were there, I think it was either Opa-Locka or Miami Gardens, we took care of a family. The family wanted to know if we could take care of their family that was in Homestead. We explained we were not in Homestead.

Dr. Rodriguez: It's a long drive.

Dr. Greer:The next visit, they had the family from Homestead move into their house.

Dr. Rodriguez: Oh my gosh.

Dr. Greer: So that way, we could take care of them. I mean, that's how successful it was.

Mitch:I know I'm the layperson here hopping in, but at The Scope, we've done 2,000, 3,000 interviews. I've edited almost all of them, and I hear about results that people get awards for and stand up and clap, and they have full funding. Say that one more time, the retention rate of these participants.

Dr. Brewster: So the retention rate of a population of low-income, undocumented oftentimes, and all uninsured was, for 12 months, 83%, and 24 months, 77%.

Dr. Greer: And the other thing that becomes very important is because we're putting students in these communities and in these households, they learn, and also because of the mentorship of the faculty, the virtues that we don't have in medicine: humility, empathy, compassion. These are the type of things that are really, really missing.

If you look up the definition of wisdom, humility is the first thing that comes up. So, apparently, there are not a lot of wise people in my profession. So it becomes important that we bring these out and we point these out, and we say, "We need to change our structural way of doing medicine." Not just the reasons I had outlined, but also because it becomes a very toxic environment.

I mean, I'm a physician. I've been a physician my entire professional life. It's about me and climbing and how many titles I have. Whereas it's supposed to be we're here about service. We're supposed to improve the health of individuals.

And as a medical school and as an educator, it becomes our responsibility not just to produce a future workforce, but to improve the health of the community that we're working in. Because things become very regional.

Dr. Rodriguez: Absolutely.

Dr. Greer: But the most important aspect of all this is that we go into these communities and we build trust. Why is that important? Let's just look at COVID where the black and brown communities sacrifice illness and death more so than anybody else, and why would they trust us?

And everybody is just saying how incredible this telemedicine is. "This is great technology." Well, that was originally developed for rural and very poor communities. What happened during COVID? Well, since we hadn't allowed them into the health system, they had no physician or nurse. So, at telemedicine, you have a patient on one end and a health professional at the other. Well, guess what? Only the insured got to take advantage of telemedicine.

Dr. Rodriguez: Only the people who already had access. You're absolutely right. But what a great story. I'm delighted that you guys are in Las Vegas. Las Vegas is only five and a half hours away from Salt Lake. So I hope we can get you up to visit us in Salt Lake City . . .

Dr. Brewster: Absolutely.

Dr. Rodriguez: . . . as we try to make things happen the way you have. This is really a miraculous change in how we see medicine.

And what you were sharing, Dr. Greer and Dr. Brewster, we believe that. Not just the entire physician core or the faculty, I think that we believe that in our deepest personal convictions. But what happens is the pressures on the outside push into that, "How many titles can I have?" and, "How much work am I going to do in administration and these things?" when what really matters is fixing the problems for the least of us.

Dr. Brewster: Yeah, we have to place impact over success.

Dr. Rodriguez: Absolutely.

Dr. Brewster: I meet students all the time and they tell me that something was successful because they received an award or they got an acknowledgment. Well, that's great, but what did you change? What did you impact?

I can't get off without underscoring the value of a dean like Joe Greer. All the other deans have the same opportunity to do what he's doing, right?

Dr. Rodriguez: That's true.

Dr. Brewster: We can never lose sight of that, right? Everybody has the opportunity to do this. They all have the opportunity to mobilize the team that he did, but they did not.

And so my sense, and the sense of many who have worked for him, is that he basically is putting his career on the line for each and every household we go into. And so he should be commended for that.

And when you look at it in the long term, no matter what happens, there'll be a number of young people who come through the programs who can now never say that it can't be done.

Dr. Rodriguez: That's right.

Dr. Brewster: That's the most powerful piece of this whole thing.

Dr. Greer: And when they see what we're doing, they can also say, "Maybe I can do it better."

Dr. Rodriguez: Oh, beautiful.

Dr. Greer: We're producing that future workforce. And Lu and I have the advantage of going to Catholic school, so we learned very, very early that it's easier to ask for forgiveness than it is for permission.

Dr. Brewster: Exactly. And all that time in the principal's office and talking to Brother Paul really does pay off at the end.

Dr. Greer: You had a Brother Paul too?

Dr. Brewster: Of course. Who didn't have a Brother Paul?

Dr. Greer: Okay, I'm sorry. [inaudible 00:18:58].

Dr. Rodriguez: Look at that.

Dr. Brewster: Everybody has a Brother Paul, and I'm sure that Brother Paul is somewhere probably talking to my son.

Dr. Greer: That's right. Exactly.

Dr. Brewster: Telling him, "I'm worried about you."

Dr. Rodriguez: How many times have we heard that?

Dr. Greer: That's right. How many windows have I cleaned at the high school?

Dr. Rodriguez: Oh my gosh.

Dr. Brewster: Exactly.

Dr. Rodriguez: Well, this has been just completely inspiring. Thank you for your absolutely spectacular work and for your wonderful presentation of it. And I am looking forward to meeting more with you as time goes on at University of Utah Health.

Dr. Brewster: Come to the school. Come see us.

Dr. Greer: That's right.

Dr. Rodriguez: Oh, I go to Vegas all the time.

Dr. Brewster: Yeah, come see us.

Dr. Greer: Come see us. And by the way, thank you for the work you're doing.

Dr. Rodriguez: Oh.

Dr. Greer: Because that is, I think, essential for improving the health of this country. It is essential. And the more we diversify medical school, the better our profession becomes, period. There's no question about it. We've seen it in business.

Dr. Rodriguez: Of course.

Dr. Greer: We've seen it in everything. I mean, there's no reason not to. And we also have to really consider and re-look at what are pre-med requirements.

Dr. Rodriguez: Oh, absolutely.

Dr. Greer: I mean, how great would it be to have a student that understands the world and not just science, and then can apply science to that world? Understands cultures, understands how to be tolerant and accepting. It has to come from the top down. I think we have the most diverse senior faculty that you're going to find in this country.

Dr. Rodriguez: That's wonderful.

Dr. Greer: And diverse not just in race, ethnicity, and gender, but diverse in your past education.

Dr. Rodriguez: Oh, wow.

Dr. Greer: So MDs aren't going to resolve this problem because we're not trained for it.

Dr. Brewster: Tell them who created Uber. Who created Amazon?

Dr. Greer: Right. It wasn't a cab driver that created Uber. It was not a retailer that created Amazon. So unless you bring ideas from the outside and say . . . And the first question we have to ask as medical educators is, "What are we doing wrong to get us to this point?" Not, "What did they do wrong?" And how can we change our behavior and what we do?

Dr. Rodriguez: Absolutely. I think introspection is key to changing how we do business. But honestly, this has been one of the best conversations I've ever had. I look forward to going there and I look forward to seeing you guys up in Utah.

Dr. Brewster: Thank you.

Dr. Greer: Come on down, because we want to change, "What happens in Vegas stays in Vegas." We want it to be, "What happens in Vegas, the world knows."

Dr. Rodriguez: Absolutely. At the very least . . .

Dr. Greer: And it's not because of iPhones.

Dr. Rodriguez: Okay. You got it. Thank you.

Dr. Greer: Thank you.

Dr. Brewster: Thank you.

Mitch: Again, we are at The Scope. We are here at the AAMC Learn Serve Lead 2022 conference, and having conversations about how we can change medicine from the ground up.

Dr. Greer, Dr. Brewster, and Dr. Rodriguez, thank you so much for joining us here on the exhibit floor to have this conversation.

If you are listening right now and you love this conversation, would like to hear more, we have plenty that we've gotten here at the event. You can hear those at uofuhealth.org/aamc22.

And if you're interested in any other health-related podcasts, talk shows, basic information, you can also hear more of me at thescoperadio.com.