How Can We Make Specialty Care More Accessible and Affordable?

[00:00:00] Jared: Hello everyone and welcome to the Med Design podcast where we explore the journeys of medical innovators. And this week we have a true healthcare leader with us, Dr. Spencer Dorn. Dr. Dorn is a gastroenterologist with over 17 years of experience in the field. He is currently the UNC Department of Medicine's Vice Chair, where he enhances existing care processes to better meet the needs of the population served by the department's over 600 clinicians. As a physician, he cares for adults with acute and chronic GI conditions and has a special focus on functional GI and motility disorders. Dr. Dorn is also a lead informatics physician working to optimize the use of the Epic electronic healthcare record. He has also co-developed applications to improve scheduling and test result communication, really reflecting his deep interest in using digital health technologies to solve tough problems.

His expertise in clinical care, academic medicine, and digital health Dr. Dorn's really a true asset to the healthcare industry. We're really honored to have him on today and just welcome Dr. Dorn. We know you're one of the busiest people we've talked to.

[00:01:00] Spencer: No problem. I'm not that busy.

[00:01:02] Jared: Let's see. So let's get this started off with just talking about what motivated you to go into medicine initially and then subsequently into academic medicine?

[00:01:11] Spencer: Yeah. I say this kind of jokingly, but it's actually the truth. I have an identical twin brother. When I was like six or seven years old, our father said to us you could either be a doctor or a lawyer. He he became a lawyer. I became a doctor, how it worked out. But I feel I chose to become a doctor.

I've had lot of good fortune and a lot of guidance along the way. And I started with my father, who, I don't know if he was kidding or not, but he certainly want us to get a great education and and contribute back. But I've always been interested in just in people and, I liked science, I guess like most pre-med students do, but it was more the people.

Being able to work with people, serve people in meaningful ways that really attracted me towards healthcare. And I've been fortunate to wind up here.

[00:01:51] Jared: Also just curious of gastroenterology as your specialty. Why did you choose that over others?.

[00:01:57] Spencer: Yeah. So, I guess similarly when I was in medical school, I realized I wanted to work with people with direct frontline patient care.

I was interested in working with people with chronic illness and I just really liked internal medicine. I chose that as my residency. Cause it just seemed like a nice way to to serve people with chronic illness. And while in residency I realized, I want to become a specialist.

I like to have focus knowledge. I like to I guess master what I'm interested in. And gastroenterology really called out to me for a few reasons. One is that's a very varied discipline. As you mentioned earlier, Jared, we do acute illness, we do chronic illness. We take care of people in the hospital, outside of the hospital.

We do procedures and we also do purely cognitive work. So it was a nice blend there. And then second and really what brought me to UNC was my interest in mind body medicine and how the minds in the body are intimately connected. And perhaps nowhere more so than the gut. We've all had butterflies in our stomach if we're nervous about something or we say we use words like we have an upset stomach, right?

We just feel a lot of emotion and good and bad stress and a lot of things in our bodies, but especially in our gut. So that was really what attracted me to gastroenterology specifically within medicine.

You actually brought up a really interesting point that I wanted to bring up next as well.

[00:03:07] Jared: So you talk about, you know your approach to integrating body and mind in, patient care and, for myself . I'm someone that works on, trying to quiet my mind for that same reason, and through meditative practice. And where would you say that the mind has that impact on the body?

Also just for your patient care as well, how do you integrate the two? How do you treat folks for mind and body?

[00:03:30] Spencer: Yeah. Like you said, the mind of the body are intimately connected. They don't live in different rooms. They're the same side of, or different sides of the same coin.

If we're not feeling well physically, we'll feel unwell emotionally. If we're not feeling well emotionally, we'll feel unwell physically and vice versa, right? If you ever step out of a hot tub, your body's all relaxed. Your mind is really relaxed. Why? Because your muscles are relaxed. And there are plenty of examples of that, that we all experience in daily living.

Try to bring that aspect to my clinical practice where I work specifically with patients who have what's known as disorders of gut brain interaction, what used to be called functional GI disorders. These are conditions like irritable bowel syndrome and gastroparesis and cyclic vomiting syndrome.

These are conditions that often have no structural basis on tests. So we do tests on people. Usually other gastroenterologists have done tests and they all look normal, yet the person's still suffering. So they wind up seeing me eventually, some of them. And I try to one, just bring an openness to discussing and understanding what it is that they're experiencing.

Not only their symptoms, but how their physical symptoms is actually impacting the quality of their life and what their main concerns are and what they think is going on. So I think a lot of it comes to listening and then trying to probe and see do they see a connection between other factors in their life and their physical symptoms or their physical symptoms and other factors in their lives and letting it develop organically.

Can't force that. Those types of insights. But I've discovered that most people have some awareness of the role that the body is having on the mind and the role that the mind is having on the body. And with that awareness there's opportunity to explore and to try and work on both, right?

To try and work on both to reduce suffering and improve health.

[00:05:13] Jared: This brings up a memory of mine when I was in college and had a lot going on in family and work in school and I started to have all these physical symptoms that were popping up. And of course, I was on the internet, I was on WebMD and I had found all these illnesses that I had self diagnosed myself with.

I went to the doctor and I was like, all right, I have all these, symptoms and I'm pretty sure I have all these illnesses. And they did all the tests and they were like how was your stress levels? How was your mind? And I didn't even think of that.

And that's actually what we ended up treating more so than any other physical symptom. And of course, it turns out that general anxiety disorder was some somewhat involved in Yeah, those physical symptoms. And so often in your practice, would you say people maybe fall onto that trap as well of self-diagnosing before they even talk to you?

[00:06:05] Spencer: Yeah, it's interesting. I've been thinking a lot about self-diagnosis because the first wave of self-diagnosis was Google and WebMD and those types of things. And of course now everyone's talking about, large language models and generative AI and chat GPT and you have to imagine that there'll be even more self-diagnosis when the tools to do so get even better.

And sometimes that may be a good thing, right? In democratizing information and assuming the information is accurate and not hallucinated as the jargon we're using. But sometimes it could be challenging too, right? If you have an ordered list of potential diagnoses and it's almost certainly number one, but number 10 is something horrible and it's on the list, but it's super unlikely and you're reviewing information outta context. That can I think be very stress provoking. It could lead people down the wrong path Not to sidetrack too much, but my general feeling with technology is technology.

We use these tools and sometimes the tools are great for what we're trying to do. Sometimes they're not, and we have to be very mindful the tools that we're using in both the pros and the cons of using the tools. Sometimes the type of tool could be great if you're worried you have strep throat and it's very, basic couple days of sore throat and maybe a little bit of swollen glands.

And I go on this little symptom checker and tells you, ah, it's likely to have it, or maybe you don't, fine. It's not gonna be too stressful, but what if it's something more serious or more chronic? I don't know if I answered your question Jared, or if I just start side sidetracking goes.

[00:07:24] Ty: You're bringing up an interesting point, which is you've got some tools that you can have a discreet logic to them where you have some kind of electronic patient reported outcome, like process for, do you have covid or not? And yeah. Go through a decision tree to then help, impact a broader population health. But then as you're describing it, where like the mind body connection between brain and gut and how complex that is.

Yeah. From a diagnosis standpoint where it takes a little bit more empirical work in order to arrive at some kind of diagnosis, that seems like the kind of thing that the technology tools are a long ways off on being able to support. Is that an accurate take on things?

[00:08:02] Spencer: Yeah, I think that's right. I think that you know, the chat bots that are in existence today are largely deterministic, right? It's simple programming if A then B, very linear, and you can't program the whole world like that, right? I think that's the major breakthrough with machine learning, neural networks as it finds patterns that you can't program every possible scenario.

Whereas these language models just probabilistically can suggest what the next step is. So I think the challenge is twofold. One it can be very useful at times. I'm not one of these physicians that says, no, there's no use for these technologies. It can often be very useful but again, only in the right situations.

And then two, with regards to your question, Ty, not everything could be coded very clearly like this. There are a lot of subtleties and nuances and areas where we don't have clearly mapped out understanding or evidence bases or literature that if we try and apply these language models to those areas, I think we'll get wrong answers because there's not enough there to actually do the work. Going back to the strep throat example, language models should be very good at diagnosing whether a sore throat is likely to be strep or unlikely to be strep or covid symptoms, as you mentioned. But certain other things, I think it could be detrimental trying to apply large language models to different areas of medicine that are maybe perhaps less well understood, more nuanced et cetera.

And then of course, it's delivering, it's not just uncovering the pattern, but how do you explain the pattern? And machines can certainly explain things. We're social beings. And often I believe a lot of the art of medicine and the benefit of medicine is through the human connection.

Again, you don't need it for managing strep throat necessarily, right? You don't need some deep human connection. Just go to an urgent care doctor, or doctor online and get what you need. But for some things especially the conditions that I help people manage, I think human connection's really important.

[00:09:46] Jared: Absolutely. I did want to talk about the healthcare system as a whole, but we've been talking about digital health already, so maybe let's talk about that. We just wanna get your opinion on what really is digital health to you?

How do you define it and like, why is it important for patient care?

[00:10:00] Spencer: That's a great question. Everyone has a different definition of digital health. I think the World Health Organization has one that, some people consider the standard but digital health means so many different things.

Depending on where you're coming from. To me, digital health, they're a set of information technologies, right? This is not hardware necessarily, this is not like an implantable defibrillator. That's not digital health. That's a device. It's more information technology, whether it's something like we're doing now.

Information technology that allows us to communicate or access information or apps. Electronic health records technically are digital health. So it's any sort of in my mind, information technology that allows us to either allows patients to better serve themselves and allows clinicians to do their jobs hopefully better or allow the two to communicate more easily. That's how I see digital health from a relatively simplistic framework.

[00:10:47] Jared: And I know part of the system that you've worked on directly is that EPIC health record, right? Yeah. And so what was the problem that system is solving and where is it at right now as far as implementation goes?

[00:10:59] Spencer: Epic is certainly the largest electronic health record being used in health systems, not necessarily in community offices unless they're part of a health system. And when I started practicing, when I was a resident just out of medical school, we were using paper, right?

We were using paper for writing our notes on paper. Well the notes were hard to read because I write like a doctor, it's really hard to read my writing. So one challenge is the notes were hard to read. Another challenge was actually getting the note, right? Like you couldn't access it from anywhere.

You had to go to a physical location to open a physical binder and look through. And information was less accessible. It was less easy to share information. That was one challenge that electronic health records solve is that it makes clinic notes more easily accessible to others.

It's caused other problems, by the way, like a side effect is our notes are often now bloated with extraneous information and sometimes there's a lot of nonsense in there. So they're more legible and more accessible, but sometimes, harder to actually understand. But that was one problem that electronic health records solved for is making clinical information more easier to access.

The same holds true for laboratory results and imaging study results and a whole host of other types of information. A second problem that electronic health records help solve for is a lot of the business aspects of healthcare. Things like scheduling and registration and insurance verification and billing and collections and all these other aspects related to the processes and business of healthcare.

Electronic Health Records helps solve for as well. The challenge with electronic health records is they're not optimized for one task specifically. They're kind of all purpose type technology that at least for Epic and large health systems, that has to do so many different things.

So therefore, often individual users are not thrilled with their own, base of that application because it wasn't built necessarily just for them. But the things that epic and similar systems do well as it does a little bit of everything in it on some level integrates all these different activities.

So if I write a clinical note that could then go to a billing team who could drop the right charge, and there's going to be a revenue cycle management system that will keep track of that charge and when the revenue has come in. So you could see how it serves various different functions.

[00:13:09] Jared: Is there maybe an evolution of the current system that we have now that maybe you would look forward to down the line maybe like 10 years from now that obviously right now, epic is working, it's up and going, in your practice technology's evolved over time already.

[00:13:22] Spencer: Yeah. The challenges, there are a lot of sunk costs. Health systems have spent literally hundreds of millions of dollars investing these systems and these are all purpose systems that do a bit of everything, don't necessarily do everything really well. So I think it's unlikely we'll move away from these in the short term.

But, thinking ahead to what's possible what do we need? We need better ways of managing information. Most clinicians, nurses, staff, are overloaded with information just like you're probably overloaded with email and texting and slack and all the other communication channels you personally use.

Same thing on the healthcare side. And there's tons of different types of information that's flowing in. Test results, patient requests notifications of appointments. And there's all this information that's just bombarding the inboxes of clinicians. And it's just very hard to keep up with.

It almost becomes its own job in itself. It's really sped up the pace of medicine and not that these challenges didn't exist 20 years ago, I just think they did. But they're magnified now and everything's a lot faster, just like the rest of our world is moving a lot faster as well. Ideally as we move forward we'll mindfully design tools that help sort out signal from noise, like this is something you actually have to pay attention to, this isn't.

And hopefully help streamline and or automate a lot of the tasks that are very time consuming. That don't necessarily need a physician or a nurse or even any type of person to do. So I hope that's where we head.

[00:14:45] Jared: It seems like in the future there might be some sort of AI bot assistant that handles quite a bit of that for people.

[00:14:51] Spencer: There already is. It's already under development in many different capacities. Machine learning is being applied to a lot of this already by Epic and by other startups and vendors. So yeah, I think that's where we're heading.

[00:15:01] Ty: And it seems like the process for creating the electronic health records hasn't been very human-centered.

And case in point for that, at one point in time there was the triple aim, which is around experience of care per capita cost, population health. And then it seemed like, as one of the articles I was reading was that as electronic health records came out, that there were so many follow on problems, they expanded it to the quadrupling.

Which is, we needed to think about the providers satisfaction because of how onerous all of this data gathering has been put upon the providers. And just wondering about the opportunities there for, not just adding AI into the mix, but making it so that it's a more curated and human experience that gives just the information that's needed, not necessarily gather all the information and put too much burden on the providers and staff and everything.

[00:15:53] Spencer: Entirely. And as a design thinker, you would be amazed if you saw some of the user interface that's often used far behind what you use in your daily life.

This Zoom call is pretty easy for us to do, right? The technology's very usable. It's very simple and streamlined. But a lot of electronic health records, they're information's hidden or put in fonts that are hard to read or too many clicks to get to what you need to do in the workforce are very complicated and cumbersome.

That's one aspect just from a designer and a usability perspective. But then as you mentioned, a lot of these systems were developed with a lot of bolt on. So they started with one product and then they realized there was a need to satisfy some other demand somewhere else. So they're almost like Frankensteins in a way.

All these parts get added on and added on. And they may not flow well together. And they're also often built on a very old technology chassis that could be decades old. So you're actually, it limits the design possibilities now. There's a lot of what economists would say is path dependence, right?

These decisions that were made 20 or 30 years ago are still affecting the design today. I agree and I'm hopeful that we can find ways to bring design thinking and more human-centered design into improving these systems. Not that physicians or nurses or schedulers, not that they've been completely ignored, cuz these have been built in partnership with them. But there are challenges. And another thing I'd say is healthcare is one of the few industries where we've digitized. But we haven't necessarily experienced the full benefits of that digitization. If you look at healthcare RAND, which, the big thing tank RAND in around 2005, I believe, predicted all the cost savings we'd have if we just digitized healthcare with electronic health records.

Guess what? Nearly 20 years later, we've yet to realize those benefits in terms of cost or quality or safety. So we've done a lot of work and there's been a lot of investment, but we haven't necessarily reaped the benefits of that in part because of the design of the systems. It plays a large role, I think, in that.

[00:17:43] Ty: To that end, the cost of healthcare have been skyrocketing as far as industries go. I mean it's like the number one, number two industry in addition to like education that have just had skyrocketing costs associated relative to the value I think the US population receives in terms of overall population.

[00:18:02] Spencer: Yeah, I think it's close to higher education. If you look at how much college costs 20 or 30 years ago compared to now, it's even, compared to where you and I were in school it's incomparable. And it's similar just, year after year outpacing cost growth, outpacing inflation.

Part of that is due to right design issues but there are clearly many other factors playing a role.

[00:18:21] Jared: You make an interesting statement on LinkedIn where you're talking about that you literally work in the belly of the healthcare beast. So in what ways is the US healthcare system a beast in some ways?

[00:18:32] Spencer: I think it's a beast in that no one would've designed the system that we have today.

If you started from scratch and first principles you would not have built what we had, and I'm not saying any one specific healthcare system. I'm saying the system, the overall system would never have been designed this way. And I'd also say that individual healthcare systems, regional healthcare systems, local community systems, even many, small offices probably wouldn't be designed the way that they're designed right now.

If you could start from scratch either. So I think that's what I mean. The healthcare system's wonderful in many ways. If someone has needs and if they can access the right care and they're fortunate enough to be guided in the right direction, there are amazing possibilities for improving lives, for saving lives, for extending lives.

Everyone's ready to beat up on healthcare. I'm not one of those people. I don't think we should. I think it's just, this is just the circumstances that over years of organic development with certain decisions that were made at different points in time.

For instance, the decision to make employer-based insurance tax deduction, like that's a massive decision that was made many years ago. That's influencing all of our so many aspects of our system. There are so many of these decisions, large and small, that have been made over years by government regulators, individuals, health systems that have affected where we are. And that's why we have the beast. That's why we have a system that often is too inaccessible, is inequitable, does not deliver the value, as Ty said, that ideally it should. So the healthcare system in many ways is wonderful.

But in many ways it isn't. And when you say the belly of the beast, just cause I'm a gastroenterologist, so I guess that's why I put it on, it's a little play on that.

[00:20:03] Jared: And when you think of accessibility and affordability especially with specialty care, for example I don't really think that the first thing that, patients think of is it being necessarily affordable, and so how do you think that we can, in the future, work towards making specialty care more accessible and more affordable, more equitable?

[00:20:23] Spencer: Yeah, so this is something I'm very interested and passionate about as specialty care as a specialist. As someone who's operated specialty practices and now works assisting multiple specialty practices we need to make specialty care more accessible, more affordable, more effective.

And if you look at what's happening nationally right now, there's been a lot of emphasis on primary care as there should be, because primary care is foundational to good healthcare and good health. Primary care has long been neglected and underfunded and underinvested in. So I applaud all the primary care efforts that are happening right now.

And I'm sure you've read about many but specialty care is often where a lot of the costs accrue and often where the sickest people wind up. So we have to simultaneously improve specialty care. And in my mind, again, this goes back to how do we design care right now we often have one size fits all models.

For instance, if someone has mild heartburn or if someone has severe Crohn's disease, they get referred the same way to a gastroenterologist and they wait just as long to see the gastroenterologist and they see them in the same office with the same personnel in the same resources. It just doesn't make sense, right?

So we have all these one size fits all models where people really have individual. Needs and preferences. So I believe we need to redesign care in ways that are better tailored to individual needs. Not necessarily millions of different types of care, although that would be nice. But let's at least start with, Five or six different types of care for newly referred patients that align with their needs and align with their preferences.

And I think that will get us much farther towards improving health towards making care more accessible, making care more affordable. I think that's the direction we need to go into building more models of care. Identifying what the needs and preferences are. Developing an operating system that matches people based on their needs and preferences to the right type of care for them.

You brought hopefully not too abstract. That makes sense. Yeah. You brought up one size fits all as the, I don't know, the default for trying to design some of these systems, which think about from a bell curve standpoint, you're trying to capture like the 50th or 60th percentile, where oftentimes from a design thinking standpoint, we're more interested in the tail of the bell curve.

[00:22:28] Ty: Yeah. Because those are the places where, you know, like on the fifth percentile, 95th percentile, really small population, specialty disease states. Those are the points in which the failures in design occur because the median is going to be just fine. But it's on the tail end of somebody who's very large or very small, who like, has varying levels of ability and mental abilities.

Those are the people who are gonna be most impacted by failures in design. And the people who, as many of the tales as you can design for is the term was universal design back when I was going through school. But those are where you try to like, make sure that the overall system doesn't fail. And it's, trying to get away from the one size fits all approach.

[00:23:14] Spencer: Completely. Just to put this in kind of real terms for your listeners someone who's really sick, someone who has really severe illness, complex psychosocial situation, whatever it is they've major your needs if they come into the traditional doctor's office for a 30 minute visit, for a doctor working alone, not on a team.

It's a major mismatch, right? There's only so much that could be done in that 30 minutes by a physician working by themself with someone who maybe has multiple chronic illnesses, complex psychosocial situation, et cetera. The flip side, what happens when someone has a very mild condition and they're sent to a hospital system and they wait a long time. So someone with mild, let's say mild reflux someone with mild reflux does not need to wait to see me, does not need to wait months and months to see me in a hospital-based facility. You know what, for right? Like their problem could be solved or largely their needs can largely be met much more excessively, much more affordably, much more conveniently.

I think that's something that would, I think, align with what you were saying Ty, about the tales right? If you're on either end and if you're forced into the same model, it just doesn't really make sense. So yeah, I think I'm a big proponent of trying to right size care so that people with complex needs are met in well-resourced models that have teams working together, not just physicians. Teams working with the right resources to solve the need. And those with straightforward needs can often be served, sometimes purely online. A lot of these virtual first companies that have popped up very good for that. Or at least in a low cost, highly accessible setting with the right personnel.

[00:24:50] Jared: We've been talking a lot about the changes that sort of need to happen, but at the end of the day, if we need those catalysts of change to drive it, and so are these catalysts gonna be healthcare organizations? Are they physicians, are they insurance companies? Like where really do we have to start as a society, putting our focus towards to actually enact these changes over time.

[00:25:12] Spencer: I don't know if I'm qualified to answer that question. I do think a lot about healthcare and the system broadly and then the individual components. I think it has to happen at the grassroots level. Change is so hard, right? No one likes to change.

It's hard for individuals to change. Now, think about changing organizations of individuals and usually there has to be a motivation to do that. We had a big motivation with the pandemic, right? We had to quickly pivot away from our decades long model and move care online, right? So it can happen, but there needs to be motivation to make it happen.

Whether that motivation comes from competition, I think that's part of it. If you look at some of the developments vertically integrated or healthcare organizations that are CVS, Aetna just made a large acquisition last week. And keeps acquiring and Optum United Health Group.

These are large corporations that are now starting to span the entire spectrum of healthcare. Will those organizations force the traditional incumbents to say, We've gotta change. Will that be the motivation? Perhaps. Will the motivation be the record levels of burnout and unsustainable practice that is happening right now?

Maybe that's part of it as well. Will it be motivation just to serve our communities better? Realize that there are opportunities to do better, to reach more people more effectively. So I think there are many potential motivations. Threat based and opportunity based. I guess threat and opportunity are intertwined in a way.

How do we harness that energy, that need to reexamine what we're doing and then actually do it actually change, actually intentionally think about why are we here, what are we trying to do? How can we do it better? So I guess that's, I don't know a long-winded answer.

[00:26:44] Ty: No I love that. Cause you touched on just grassroots as a driver for change and I think it's so easy or so much of like historical success for healthcare innovation has come from some new technology the invention of the Foley catheter or the pacemaker that have had such profound changes in just quality of people's lives because they've been able to be a direct technology intervention in healthcare.

Yeah. And I think what we're seeing is an overabundance of technology in the space where our entire innovation process is set up to put one more piece of technology into the use case, and that may not necessarily be the right answer. It could be that the right answer is to remove technology or to like, fundamentally rethink how the human beings that are involved in this behave and act in interesting ways.

And so that's part of what we've been doing with med design is starting with, let's ask the physicians and clinicians to fully define what are the key problems in healthcare, and then try to pattern match from there to try to find what's the best pathway forward rather than start with a thesis about a technology.

Yeah, so I think it does come with that shift in mindset and thinking to be able to start making some of these big changes.

[00:28:02] Spencer: Yeah, I totally agree. When we think about innovation, we do tend to think about the Foley catheters, the new devices, and they're critically important. What really saved our society from the pandemic, not to minimize all the suffering that it caused and the loss was the vaccine, right?

It was rapid development of mRNA vaccine and technology. More than anything else that we did. So those breakthroughs, hopefully they continue to occur. Breakthroughs in treatment of cystic fibrosis has really revolutionized I'm just thinking of a recent example. It really revolutionized how we take care of people.

At least that's what my pulmonary doc friends tell me. So all those things, new drugs, new devices, new diagnostics critically important. And at the same time I think we have to think more about how we deliver care, how we deliver those interventions, how we organize ourselves. And I'm hopeful that that we'll make progress there as well.

Personally, think so as well. I do wanna talk a bit about academic medicine, your transition to that from being a physician into academic medicine now. What are those challenges you face that are different from working in a private practice? And I guess how do you deal with those as well in the new system you work in?

I guess I'd say I've always been in academics. I've always lived my life on the semester calendar, I still do. So I went, college to medical school to residency to fellowship, and then right outta fellowship I joined the faculty practice here at UNC.

So I've always been in academics have not lived in the outside world. So maybe. There wasn't much of a transition. I'm not sure. I think what's different about academic medicine compared to community practice or non-academic systems for one is we have several missions. Clinical care is certainly one of the main missions that we do.

And it's the one that I focus on most at this point in my career. But it's not the only one. We have people learning with us, medical students, residents, fellows, other visiting people. So there's a big emphasis on education and training others. So that affects how we run things.

And then research and discovery is the way that the mRNA vaccines were developed is based on research that was done at University of Pennsylvania and other systems. Both, fundamental basic research, translational research, and clinical research leading to discoveries that ultimately reach the bedside.

So I think that's the core difference of academic medicine is that we're engaged in all three of these different activities and we need to balance them all. How does that differ from regular practice. When a patient comes into an academic system there may be people that are interested in recruiting them for research studies.

Research studies of course happen outside of academics as well, but there may be more of an emphasis on that. Or there may be trainees involved in their care. Sometimes when I do GI procedures like colonoscopies, I'm working with a fellow supervising them as they do it.

Those types of things. That's I think how academics fundamentally differs. It's a beautiful for me, it's a beautiful place to work within because there's just a lot of variety and especially colleagues, right? You have colleagues who are generally curious and often at the forefront of their field.

So it makes it really enjoyable. But it is a little more challenging in some ways because we have to make sure we're attending to each of our missions.

[00:30:56] Jared: Something you talked about as well was balance and even before, as well as burnout. And that's something that we've come across a lot as well, talking to other physicians.

How do you manage your time? Because during my introduction, you have your hands in so many things right now, and so you know, as somebody that is as busy as you are, how do you find time to just be a human being at the end of the day and not succumb to the burnout of many of your colleagues

[00:31:20] Spencer: Really?

I don't know if I'm as busy as you're stating. I like to think I have, I'm not overscheduled completely. One thing is I'm, I don't see patients every day. I have different responsibilities and those different responsibilities are actually funded responsibilities.

They're not unpaid obligations always. So I have time that I can dedicate to my different roles and I see patients part-time. So my colleagues who are seeing patients full-time Have different challenges. They may not have as many meetings to go to or as many proposals to write or people to convince of different ideas.

But they have a lot of labs to follow up on, a lot of notes to write, a lot of patient calls to return. So that's really hard. It's really hard if you're doing that day in and day out. And I've just in my career, managed to go down different path that gives a little more variety to some re extents that I guess frees me from some of the challenges that many of my colleagues face.

I'm trying to help them with those challenges by the way in the time I'm not seeing patients. And then I think just self-awareness is important to me. Cultivating a sense of self-awareness and knowing what I like to do and what I'm good at and what I don't like to do and what I'm not good at.

I think trying to keep balanced perspective of what's most important. I'm certainly not perfect at this, but, I do try and take time to reflect and for contemplative practice. Very supportive family. Just feel fortunate that I've been able to do the work that I do.

Supportive mentors, supportive boss, who's wonderful. So yeah, I think I certainly haven't figured it out. I don't know if any of us figured it out in the modern world. But , I guess I've been fortunate to have people helping me and along the way.

[00:32:48] Jared: Sticking on the topic of burnout, you know, we've seen it on social media physicians or clinicians talking about.

they work a shift and they have just so many patients. They can't even keep up with people. Maybe sometimes like in the hospital they're understaffed. And I've seen this a lot since Covid happened, right? I feel like this has been in the news quite a bit more since Covid happened, but is this a function of the way the system was designed or is there a shortage of people that are qualified to do this work?

or yeah. Why is it that there's just so much falling on, clinicians and physicians at the end of the day?

[00:33:20] Spencer: I don't think it's a new phenomenon. I think it's just more, I think it's it's more extreme now and it's more in, in public awareness. I think, if you surveyed doctors in the 1970s and asked how much were they working and did they have trouble going home at night and disconnecting from work and not thinking about the cases they had during the day, and

I bet a large majority of them would say, yes, this is really challenging work. It's really hard to do. I'm stressed out. So I don't think that's necessarily brand new. I think what's different and by the way, I don't think this is different from other fields either. I think teachers, that's such a hard job.

You heard about burnout in education and I have, I've several family members who are lawyers. That's really challenging. People in business. Small businesses, restaurants, design firms, right? I think it's not necessarily unique to medicine, this feeling of burnout.

And I don't think it's a new phenomenon. I think what's different is one that Covid just placed tremendous demands on healthcare, right? It really stressed an already stressed system and it also I think, caused a lot of conflict. Or at least it raised the tension level when there are people who are being hospitalized with Covid who decided they don't want to get vaccines that probably could have prevented their hospitalization or arguing with clinicians, nurses about certain safety procedures. A lot of politics I think came into healthcare, which should really be a politics free zone. I think cuz we're all peop we all want the same thing.

My viewpoint is that. So I think that's one thing I think being on the front lines during a pandemic. We're all people too. We all have our own fears of things, right? And especially before vaccination was available, working front lines with people who were infected.

It's kinda like firemen, fire people, I should say, running into burning buildings, right? You do it cause it's your job and who else is trained to do that? But it takes a toll. It's stressful, it's stressful to work in that environment. When everyone's working from home and you're there and you're afraid to even take your mask off to eat lunch, you go outside to eat lunch because think of the early days of about three years ago when this all started, right? It was very scary. So I think that's perhaps part of it. I think part of it is that life in general is moving faster. Life outside of work is moving quickly and teenagers are more depressed and just people are more on edge.

The economy, inflation, things are more expensive. So I think that also affects healthcare workers. Like it affects everyone. Then I think there is a tipping point almost that we've reached with the burdens that are placed on clinicians who largely want to do face-to-face work and help people, and have meaningful connection. But yet there's all this digital paperwork and all these regulations and all these requirements. Make it really hard sometimes to find joy in the work. So I think it's a combination. The in basket we mentioned before, all this after hours were trouble disconnecting.

I think it's just a confluence of factors. It's hard to say what percentage of the variance each one explains, but I think there are confluence of factors that, again, not new, not unique to healthcare, but I think for people working in healthcare, at this point in time. It certainly has risen to the forefront.

And I think it's a good thing that it's part of the public consciousness. I think the public should understand that this is a hard job that people are doing. They're doing their best, but sometimes it's too much for them. And you want your healthcare workers to be happy, right?

It's hard to take care of someone if you don't feel like you're being taken care of yourself.

[00:36:35] Jared: absolutely. We're getting towards the tail end of things here. Something I did wanna talk to you as well about is, physician leadership. And so obviously you are a leader of the Department of Medicine, and I know that must have been somewhat of a transition period for you to now be leading a department versus maybe participating in it.

And so what are some of the skills that you think lead to success in a role like the one that you're in.

[00:37:00] Spencer: First of all, I have great colleagues. think and many people have helped me get to this point and like I mentioned, I'm very supportive boss who's the people around you I think are just so important when it comes to leadership because we don't do it alone.

I think humility is very important. Admitting you're not perfect and don't have all the answers, but are willing to learn. Empathy I think is super important. Understanding what people are experiencing being creative and imagining solutions. And showing, leadership in some ways is showing that innovation leadership is probably mostly about showing there's a way that we could do things new and differently. That's actually better than what we're doing now, and it's worth investing the energy together. , I think understanding the problems I'm fortunate that I practice medicine so I can understand the frustrations of the electronic health record.

I use it too. The challenges of having patient access, long wait lists. I see patients who have waited way too long to see me. I think a combination of those are things that I think that help make a good leader. I'm sure I'm leaving many out, but , what do you think?

[00:37:56] Jared: I think that's it. In my past roles of leadership, I think empathy is one thing that if you don't have that as a leader, people will start to write you off. They're gonna start to ignore you to some degree. I've always talked about leading through empathy.

And I think also people start to understand you a little bit more too, when you have this like human connection.

[00:38:14] Spencer: Yeah. I think also I think one other thing I thought of and thank you for sharing that, Jared because you're right, we're all people.

To lead people, you have to be a person. You have to be a real person. I think reliability and delivering is important, right? And a lot of it is showing up and responding to people when they have needs. We're all overwhelmed with email and texts and all that, but actually getting back to people.

Communication I guess is the other thing I would add, being able to communicate a vision that makes sense in a clear and succinct way. To build on what you were saying with empathy.

[00:38:41] Ty: You think about from a leadership standpoint, there's formal authority, which is the title that you have or the formal authority that structurally in place.

But even within the military, which is heavily regimented, relies upon formal authority. You still have that interpersonal, informal just, what can you do to provide an example to show that you're right there next to the people who are, like who are all in this together to get to accomplish the mission.

The best expressions I've heard is, was it mission first? People always. That if you accomplish the mission and yet your people are just, burned out as a result of accomplishing the mission that you wind up not being ready for the next one. And that you want to get there together.

And so it's an interesting balance to be able to strike.

[00:39:26] Spencer: Yeah, I like that mission first. Mission first, people always. Is that what it was? Yeah. Yeah.

[00:39:31] Jared: That's cool.

Yeah and I think just tying things all together for those younger physicians that are just getting started, they want to be a department leader just like you.

What's the advice you have to give them to follow along your footsteps and maybe even be greater than you were or are?

[00:39:45] Spencer: Oh yeah. I think one thing is you can't plan everything. I didn't think I'd live in North Carolina, be an academic position be a gastro, do this. I think generally when I meet young people, I advise them to point in a certain direction that they think aligns with who they are and what they believe in what they wanna accomplish.

But then be open enough to possibilities for changing circumstances for new opportunities. That come along the way. And I like to believe that I'm continuing to do that, but I think that's been useful. I think the second is to surround yourself or connect with people. Who you look up to and admire.

And not only because they're talented, but because they're good people, because you just in your heart feel like it's someone you want to be around or someone you want to be connected with. Because we don't do anything alone. They're always people in circumstances and factors helping influence us along the way.

and I guess a third would be to work hard. I guess it goes without saying, maybe that's expected. But working hard to develop yourself as an individual to develop your domain expertise. Whether it be clinical medicine or leadership or operational improvement or design thinking, whatever it is.

I think you have to invest the time and energy and efforts to develop the skillset necessary. So those would be three.

[00:40:58] Ty: To that end, of course into that med design a event. With the program we put together and Spencer, we got introduced through a mutual friend and colleague, who has been through the med design course that we've been offering.

That is something that we've been providing as a way for people who are physicians and clinicians who are interested in this path of innovation. We've got a structured course where you practically solve active problems, but then walk through really some of the fundamentals of building empathy, clearly defining the problem, and then understanding what the psychology of creativity is about.

Then actively proposing a wealth of solutions to then make good choices between. So that's some of what we're doing, and we've opened the program up now to where we're accepting applications for that. Yeah, so pioneered through UNC Fast Tracks and we're excited to see that Blossom and Flourish.

We've had a lot of just interest and excitement in the program anyway.

[00:41:50] Spencer: I think it's great what you're doing and I think bringing this way of thinking, these skillsets that traditionally have not been applied in healthcare are not at least been applied in healthcare organizations.

I think it's wonderful. There's been a big emphasis on lean over the years and I don't know enough, I think I mentioned this when when we met Ty, but someone once nicely described design thinking as the emotional or empathetic sign of lean, right? It's a different type of design.

And I just love that and I don't know a ton about design thinking, but what I do know, it just seems to really align nicely with process improvement, clinical improvement innovation, all the things that we've been discussing. Yeah, congratulations on building all that. Thank you for that.

[00:42:26] Ty: Yeah, to that end, I mean when you're dealing with complexity, human behavior, and you don't have any data, you have to go create the data. That's really where I think the domain of design thinking shines. Whereas if you're dealing with, a known data set where you can run an algorithm against it then that's where continuous process improvement comes into play.

And if you think about Lean Startup, they're pulling from a lot of the tools from design thinking. And you know, as you think about like business Model Canvas, which Lean Startup uses extensively is a practical application of this empirical guess and test approach to innovation.

[00:43:01] Jared: Yeah. That's great. We're coming up on time. We'd like to thank you again, Dr. Dorn, for giving us an hour of your time. we know that we are in great hands for the future of healthcare. The doctors that are coming out from your departments.

Thank you for all the work you do, and thank you for your time. Thanks so much. It was a pleasure to meet with you both.