EP. 46: LEADING HEALTHCARE THROUGH RELATIONSHIPS

WITH NIRAV R. SHAH

Jan 25

WITH NIRAV R. SHAH, MD, MPH

A former New York State Health Commissioner shares why meaningful relationships are essential to effective healthcare leadership.

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Episode Summary

What does it take to lead a health department with a budget of more than $50 billion, overseeing the health of nearly 20 million Americans? Here to tell us about that is Dr. Nirav R. Shah, who was the 15th New York State Commissioner of Health from 2011 to 2014. Today, Dr. Shah is a nationally recognized advocate of patient safety, health care innovation, and high-quality, low-cost care. He has variously served as Chief Operating Officer of Kaiser Permanente in Southern California, Advisor to the CDC Director, Senior Fellow of the Institute of Health Improvement, and Senior Scholar at Stanford University's Clinical Excellence Research Center. In this episode, Dr. Shah joins us to share his philosophy of healthcare leadership and how meaningful relationships anchor his work.

Nirav R. Shah, MD, MPH, is Senior Scholar at Stanford University’s Clinical Excellence Research Center. He is a leader in patient safety and quality, innovation and digital health, and the strategies required to transition to lower-cost, patient-centered health care. Board-certified in Internal Medicine, Dr. Shah is a graduate of Harvard College and Yale School of Medicine, and is an elected member of the National Academy of Medicine. Dr. Shah’s expertise spans health and healthcare as an Advisor to the CDC Director, as Senior Fellow of the Institute for Healthcare Improvement (IHI), as trustee of the John A. Hartford Foundation, and as an independent director of public and private companies and foundations. Previously, he served as Chief Operating Officer of Kaiser Permanente in Southern California, and as Commissioner of the New York State Department of Health.
In this episode, you will hear about:
• How Dr. Shah’s upbringing and the influence of Jainism steered him away from a lucrative career in finance and into medicine - 1:53
• Two patient stories in which seemingly simple mistakes led to moments of awakening for Dr. Shah in recognizing his purpose in medicine - 6:21
• A brief overview of Dr. Shah’s career path - 13:47
• Lessons on empathetic leadership that Dr. Shah picked up along the way - 19:21
• How forging strong relationships helped Dr. Shah find solutions on big issues during his time as New York State’s Health Commissioner - 21:57
• Dr. Shah’s current pursuits, including those focused on making a business case for supporting the unpaid caregivers of patients - 31:23
• Why transparency and bureaucratic structure are critical components of healthcare reform in the United States - 37:46
• Advice to clinicians on what makes effective leaders and collaborators, and how to find passion for meaningful projects - 41:43
Henry Bair: [00:00:01] Hi, I'm Henry Bair.
Tyler Johnson: [00:00:03] And I'm Tyler Johnson.
Henry Bair: [00:00:04] And you're listening to The Doctor's Art, a podcast that explores meaning in medicine. Throughout our medical training and career, we have pondered what makes medicine meaningful. Can a stronger understanding of this meaning create better doctors? How can we build health care institutions that nurture the doctor-patient connection? What can we learn about the human condition from accompanying our patients in times of suffering?
Tyler Johnson: [00:00:27] In seeking answers to these questions, we meet with deep thinkers working across health care, from doctors and nurses to patients and health care executives; those who have collected a career's worth of hard earned wisdom probing the moral heart that beats at the core of medicine. We will hear stories that are by turns heartbreaking, amusing, inspiring, challenging and enlightening. We welcome anyone curious about why doctors do what they do. Join us as we think out loud about what illness and healing can teach us about some of life's biggest questions.
Henry Bair: [00:01:02] What does it take to lead a health department with a budget of more than $50 billion, overseeing the health of nearly 20 million Americans? Here to tell us about that is Dr. Nirav Shah, who was the 15th New York State Commissioner of Health from 2011 to 2014. Today, Dr. Shah is a nationally recognized advocate of patient safety, health care innovation and high quality, low cost care. Having variously served as the chief operating officer of Kaiser Permanente in Southern California, advisor to the CDC Director, senior fellow of the Institute of Health Improvement, and senior scholar at Stanford University's Clinical Excellence Research Center. In this episode, he shares his philosophy of health care leadership and how meaningful relationships anchor his work. Nirav Welcome to the show and thanks for being here.
Nirav Shah: [00:01:52] It's really my pleasure.
Henry Bair: [00:01:53] So your career has spanned academia, the public sector, and the private sector, including leading some of the largest public health care and largest private health care organizations in the nation. Can you take us all the way back to the start and tell us what led you to a career in medicine?
Nirav Shah: [00:02:11] So I'm a pretty typical Indian kid growing up in Buffalo, New York, with immigrant parents who came here in the sixties. I was born and raised in Buffalo, and when your parents are Indian, they often give you three choices on what you can become: a physician, an MD, or a doctor. So I listen to my parents. My brother actually knew he wanted to be a doctor. I wasn't sure what I wanted to do. And after college I had an offer from Goldman Sachs to start in New York making more money than my engineer father was. And it was a very exciting. Or I could go to Yale Medical School. And ultimately Yale won out because I could always go back and do that other stuff. But being a doctor was a gift, an opportunity of a lifetime. And I'm so glad that my parents gave me those three choices.
Tyler Johnson: [00:03:03] So when you were making that decision between Goldman Sachs, which, as you say, there would have been a lot of things that probably wouldn't have been too shabby about doing that when you were making the decision between that and medicine -so I get that you had three options- but genuinely, what made that decision win out?
Nirav Shah: [00:03:22] Yeah. As much as I like to joke about making money and other interests that you want to pursue when you're young, my faith is I'm a Jain, J-A-I-N religion. And so our faith drives us to serve others. And so that service to others has always been a central theme in my life. And I've been very lucky that through my profession have had that opportunity to serve others. So the opportunity to be a doctor, to do good, to do well, to serve others, was really core to many of my central beliefs.
Tyler Johnson: [00:03:54] So Henry and I were talking the other day that we feel like there's this funny, almost an allergy among many doctors to talking about the spiritual dimension of just about anything. Right? Like if a patient starts to bring up spiritual stuff, it's like, are there a palliative care doctors here? Could we get somebody in? We need a consult, right? Like there's just this sort of almost reflexive discomfort. And so as long as you brought it up, we would actually love to know- because we feel like one of the things that this podcast has done for us has been to sort of uncover the fact that a spiritual element to practice is more important to more physicians than I think we often give it credit for. And so all that is to say that as long as you're bringing it up, could you talk a little bit about how does your your spiritual practice or your spiritual worldview help to motivate you or help to inform the way that you understand what you do in the world of medicine?
Nirav Shah: [00:04:56] Great question. For me, medicine has been the gift of connecting to people, right? You get to understand who they are, what drives them, what motivates them, and you're allowed to ask just about anything you want and get honest answers as part of the broader conversation about improving health. And it's about generosity. They are being very generous with their own stories, sharing them with you. And it's a gift to you as a physician to accept those. You understand their values, and you accept it with humility. It gives you the opportunity to then help them help themselves. That's how I see that give and take of being a physician. You're actually getting a lot, as you know, as a physician, but you're able to give what the patient needs in front of you based on their own values. That's going to make the biggest difference for them. So it's about understanding that at a deep level as a human being, with all their faults, with all their wishes, with their aspirations, and that is the basis and foundation for the therapeutic relationship that ultimately lets you to build toward health and build toward what they want to live their lives is. So I think for me, spirituality means compassion, humility, patience, integrity, very broadly. And those are the kinds of things that my spirituality brings for me into medicine and into the patient encounter.
Henry Bair: [00:06:21] So you mentioned early a little bit that your parents really wanted you to go into medicine, and then when it came to you making your own decision, you were able to articulate a reason why this was the right reason for you. And so you're in medical school and perhaps in the early stages of your clinical training. Is there a story you can share a moment with a patient that really illustrated for you why this was the right decision and why this is the most meaningful work that you can do?
Nirav Shah: [00:06:53] I'll give you two. One relates to a patient who was one of my continuity patients when I was a resident. I'll call her Miss Gonzales. Miss Gonzales was one of those amazing 70 something Hispanic women who had raised a family and was now taking care of herself finally at this stage in her life. And she had neglected to do so because of all her responsibilities for many years. Mrs. Gonzales was, you know, on a few simple medications. And I remember one time just refilling her calcium and vitamin D, and she was running out. So I didn't give her any of the other medicines, but that one I did. And then three weeks later, I got a call that she was admitted to the hospital. Miss Gonzales speaks Spanish. I do not. And for whatever reason, I didn't have the interpreter. As for that part of the visit, and she had doubled up on her doses of calcium and vitamin D. Very adherent patient. Right. And as a result, I had sent her to the hospital and almost killed her. That woke me up on many levels. Obviously, the quality and safety of what we do first do no harm was always somewhere in the back of my mind. But focusing on quality and safety became much more important to me as an individual practicing physician.
Nirav Shah: [00:08:17] And I saw and I started to study and learn about systems thinking and error and how we can minimize that. And that, you'll see, has guided me in my decisions ultimately to go to Kaiser and other places as well later in my career. But it starts in front of the patient. It starts one on one. And the little decisions you make. "Now, let's make it convenient for her and refill these scripts" can make big problems down the line. That was a wake up call in terms of focusing my career on quality and safety. The other story I'll share with you relates to a boy by the name of Rory Staunton, and his story has been written up many times in The New York Times and elsewhere. It's all public knowledge. Rory was a 12 year old boy who was at my hospital, NYU. He had slipped and fall while playing basketball at school and had a cut on his arm and was seen in our emergency room and sent home. A few days later, he wasn't feeling better. So his parents brought him back. And it was unusual for such a healthy child to not feel well. The doctors saw him. They ordered some blood tests and sent him home again. Two days later, Rory Staunton died from sepsis.
Nirav Shah: [00:09:41] Young, healthy kid. With the rest of his life in front of him. He wanted to be a pilot. He had all the energy in the world. And we lost him. That single story helped me wake up. This was when I was health commissioner of New York State. And we see the numbers. We see that 750,000 people a year are affected by sepsis, that between 20 and 50% of people who are diagnosed with sepsis die, that it's more common than breast cancer, prostate cancer, deaths from HIV/AIDS all combined. And yet it's also preventable. And a lot of the problem is hidden in the averages. When you say on average, maybe 20, 25% of patients die of sepsis, what you don't realize is when you look under the numbers, under that average, there's huge variation that's not explained from 10% to 60% death rates in New York state hospitals from sepsis. And why was that? So when you started, I started asking, and I was lucky to meet some friends, actually from Kaiser, the CEO of Kaiser at the time, said, "Nirav, you should do what Kaiser has done for sepsis. We've reduced deaths by 60%." And I couldn't believe it. So I actually looked they had published all their data and it was very simple. It was about early identification and aggressive treatment.
Nirav Shah: [00:11:09] Someone has to say or think sepsis, which someone may have done in that emergency room when Rory was there, but they didn't say it out loud. And if you say it out loud and you start a sepsis clock that has a two hour timer and you get fluids and antibiotics in that individual, within 2 hours, you're going to save the life. It's as simple as that. Doesn't matter if they have congestive heart failure, still put in the fluids. It doesn't matter if they have other issues, put in the fluids, in the antibiotics within 2 hours. It's as simple as that. And so I thought this this is too simple to be true. We can't make this... This should... Why isn't everyone doing this? Well, part of it is it's a measurement issue. And so initially it was like, do you have to hire every hospital has to hire someone to abstract the charts so that we can get true numerator and denominator? Yes, that is an expense. Then you have to report it to the state and look at the data and act on it. Now, if you're at a 10% death rate versus a 60% death rate, it means very different things. As a hospital, you don't want those data public if you're 60%.
Nirav Shah: [00:12:18] So we figure out a way to over time say we're going to share the data internally for improvement for two years before we publish it publicly and we're going to help you. And so what they achieved in the state of New York because of Rory Staunton, they're actually called 'Rory's Regulations.' This was written on a napkin at a big meeting of all the experts where I think I just wrote two things: early identification and aggressive treatment. Multiple published studies now in JAMA, New England Journal, and The New York Times have now shown that New York State has saved tens of thousands of lives in sepsis because of Rory Staunton. He was a statistic, right? The statistic was his family lost 25% of the family when he died. But that 25% went on. And his legacy is really saving the tens of thousands of kids like Laurie and adults who subsequently been saved because of early identification and treatment. So that's the meta story of what quality improvement can do and what's possible in real time just by using evidence-based approaches, being thoughtful, being inclusive, and marrying the heart and the mind, talking about the individual statistic, painting a picture around him, but also talking about what this means for the thousands of other families across New York and across the country.
Tyler Johnson: [00:13:47] Now, just to give us a framework for the discussion that we're having. Can you talk through- So you make the decision to go to Yale Medical School from that point until now, what were the major waypoints along your career trajectory?
Nirav Shah: [00:14:04] Well, some might say I can't really hold down a job because I change every few years. After medical school, I stayed on for residency at Yale as well for internal medicine, which was phenomenal. They wanted me to stay on for another few years as a fellow, but I instead elected to do the Robert Wood Johnson Clinical Scholars Program at UCLA. I moved to California finally, which was a dream for many years. My wife and I got married and unfortunately she got a job in American Express in New York City. So we after my fellowship, we moved to New York City and I joined the faculty of NYU. That's where I spent many years, almost eight years as an assistant professor on the tenure track, doing those things, writing the papers and grants. You know, it's a game. And if you know how to play the game, you rise up through the ranks. But I was getting bored of that a little. I mean, as much as the work was important and interesting, I didn't see the impact on outcomes, they say between 17 and 20 years between a papers published and ultimately practiced in medicine. And so I ignored my friends who said, "Don't do policy work till you're 50." And I switched and was doing some consulting on the side and met the transition team for at the time Attorney General Cuomo when he was just elected.
Nirav Shah: [00:15:18] And those folks said, please join us on the transition team to help pick the next health commissioner. 44 people applied for the job a week into the process. They're like, no, no, we're going to move your resume over and consider it. And so it was one of those right place, right time things where I was then considered for the role. And I think because, number one, I'm from Buffalo and the governor needs upstate representation, not just everyone from New York City, even though I lived in Manhattan at the time. Number two, I was at Bellevue Hospital as a doctor, and Bellevue is the flagship of the New York City Health and Hospitals Corporation public hospital system. Number three, I was I was actually a practicing internist, internal medicine. And they needed someone with a primary care perspective. I had published a lot on health care reform topics. I'd spent part of my time at Geisinger Health, and so I knew and published on patient centered medical home and all this other stuff. This was 2011 when Obamacare was coming down the pike. So they're like, Oh, we need someone who knows health care reform. And between Kaiser and Geisinger and others, I kind of published on it, so I was seen as an expert.
Nirav Shah: [00:16:25] Sanjay Gupta made all Indian doctors look good at the time. So I think that was one of the reasons I was also selected. But most important perhaps, was the fact that I was 38 years old and I had never actually done anything other than being a professor. So I hadn't been the CEO of a hospital or a former president of the AMA and upset nurses or upset doctors or upset unions or upset, you know, which is what you have to do if you're leading, you're going to upset people. And so they couldn't really put anything on me because I had been a professor. And I remember the senator, Republican senator, who read all my papers he had published or printed out a stack about a foot high and said, Nirav, I've read your papers -you know, I'm sure he read the abstracts- and I didn't see anything wrong with them. So I'm like "good." (laughs) And that's where it led to a unanimous confirmation hearing for me to move my family from Manhattan to Albany, New York, into a small rental house -because I was still paying off my med school loans- and start on that incredible ride of being health commissioner for New York.
Tyler Johnson: [00:17:34] And then from there, what after that?
Nirav Shah: [00:17:37] Well, that was an incredible ride of four years. But when you're health commissioner, it's a 24/7 job. I remember spending a month in the bunker after Hurricane Sandy in Long Island City with all of the mayor, Bloomberg's team and others helping manage health care. When you have eight major hospitals across the city in Long Island shut down with thousands of people evacuated from each hospital, you need people there who are allowed and able to make decisions on who goes where, what, how resources are allocated. And my wife was raising our at the time children of age three and five by herself in Albany. She didn't sign up to be a single mom. So there were there's a personal toll. I can see why they say don't do policy work till you're 50. After four years of this, where we did fairly well, I thought it was time for me to move on. I'd found a able successor to take on the role. And I spoke with the governor about my next move where I'd actually be able to see my kids grow up and spend time with my wife and and contribute perhaps at a future stage in my life in public service once again. So after that, I went to Kaiser. That was my exit. And I was lucky to have Ben Chu, another mentor / sponsor who created a role for me as chief operating officer for clinical operations for the Southern California region, 15 hospitals, 5 million people insured, and helping oversee quality, safety, their Medicare and Medicaid work, and many other roles, which was just again, a gift given by someone to me at the right place, the right time, so I can learn and grow and contribute in different ways.
Henry Bair: [00:19:21] So as you mentioned, you were given this opportunity to lead health care in New York State at a what I must imagine must be a fairly young age for, you know, for this kind of position. What was it like when they told you that they wanted you to take on this position? I mean, did you feel ready for it? What fears, concerns? What excited you most about it?
Nirav Shah: [00:19:46] Well, of course I had imposter syndrome. Like, "I have no business being here. I'm surrounded by all these incredible folks who've been public servants, who've done this for decades. And I'm just a political appointee. I'm meeting all the time with the CEOs of all the major hospitals, and they're trustees and giant egos of New York City. And ultimately, I did not belong." But they saw something in me that said they did. So I first thing I did was go on Amazon and buy five books on leadership and read them. And that really helped. So things like move your office once every so often. So I moved my office to the subsub basement of Corning Tower where, you know, I'm sitting in this office like, what is the commissioner doing here? He's never been here before. My cell phone wouldn't work. So I said, you know, "can you please put in one of those routers so I can get a cell phone service here?" And so I fixed my problem. And in the process, everyone got cell phone service in the subsub basement. They're like, "Dr. Shah loves us! He gave us cell phone service!"
Nirav Shah: [00:20:46] And another day I was going to the lunchroom and coming back the door is a one way lock door. I'm like, "Just unlock the door." "Dr. Shah loves us! We can now have lunch in the cafeteria!" And so I literally just walked a mile in their shoes. It was a mile to the cafeteria and learned a lot from them. And they went on to then cover my back. Right when things happened, I would hear directly from my people in the subsub basement, before their boss or boss's boss; the five levels of hierarchy were bypassed. And so we could move much faster as a bureaucracy by flattening the hierarchy, by having good people who trusted me, raise a flag early so we could get ahead of things. And that that story happened over and over and over again. All of the good things that happened in New York State were because of the incredible dedicated public servants who got fired every time a new administration came in, who made much less money than they could have in the private sector, but who cared deeply about service. And so I learned a lot about leadership, certainly from the books, but then moving around and walking a mile- from my people.
Tyler Johnson: [00:21:57] So you mentioned earlier when you were talking about the the story of Rory and getting sepsis under control. You mentioned this tension between the fact that you could think on the one hand about his particular story and this one thing that happened to this one person, but then use that to as sort of motivation or to put a face on what needed to be these larger systemic reforms. But how once you get into the kind of public policy and public health work where you're dealing on the statewide level, right, where you're talking about millions of people, how did you approach that in a way that allowed it to still be meaningful and to still retain sort of the heart of what took you into medicine in the first place so that it didn't just all become an abstraction, right? Like how do you keep the people and even the lives that you're saving from just becoming sort of like imaginary widgets that you're just kind of moving around, but that doesn't really have that kind of moral purchase that I imagine, well, by your own account, is what drew you into medicine in the first place.
Nirav Shah: [00:23:11] Over time, I thought that leadership became for me all about caring for individual people one at a time and leveraging the opportunities that were in front of me by working one person at a time, one person at a time, which is what gave me energy. You know, I wasn't able to see patients anymore one on one, which is immensely energizing, but I could work with one person at a time.
Nirav Shah: [00:23:36] I'll give you a quick example or two of that. We knew that in New York State, 49% of people who worked in hospitals got their annual flu shot. That means more than half didn't. And my friend in Rhode Island, the commissioner, tried to mandate flu shots and SEIU took that into court and stopped that initiative, saying you can't mandate that people get flu shots because, you know, people have concerns about flu shots and SEIU, a third of the members at the time were worried about things like flu shots causing autism or other problems. But I was good friends with the head of SEIU personally, and so he'd call me up on a Friday saying, "Nirav, we're going to shut down this nursing home in Buffalo and protest and we're going to call you these names, but we're still on for breakfast next week, right?" Or in this case, "Nirav, I understand that flu shots are important, but it can't go. We can't mandate it because of these issues. What else could we do?" And so we were able to work together to come up with a way to protect the workers in hospitals. Let's not do a flu shot mandate. Let's do a flu mask mandate. And as a result, we're protecting workers from all these sick people who are coming in. We're protecting workers, families, by extension. And by the way, if you don't want to wear a mask, you can certainly get a flu shot. So it was it was about choice. It's about an honest choice for individuals. I kept a little asterisk about the health commissioner defines when the flu season starts and ends. And of course, it starts. When does it start?
Tyler Johnson: [00:25:27] Depends on the year, usually the late October or early November.
Nirav Shah: [00:25:30] Call it October 1st. And when does it end?
Tyler Johnson: [00:25:34] Again, it depends on the year, but April, May.
Nirav Shah: [00:25:36] I think it's September 30th, so you may have to wear a mask all year round. And so the first year when and by the way, when this happens, there's a policy window you create, right? You create the policy window by. Early in the flu season, there's a little shortage of flu shots available for kids. And so we don't discount that. We're like, "yes, there is a flu shot shortage for now." And so there's a run on flu shots. The governor needs to get his flu shot. Let me make sure I give his flu shot on TV. And a lot of people were bidding for me to be able to be able to stab the governor instead of me but I got the distinction of doing that. Let's put out an ethics of a flu mask mandate piece in JAMA with Arthur Caplan, a notable ethicist. Let's get a press release by all of the different groups in health care who want to hide behind regulation of a flu mask mandate and let them support us. So I can go to the governor and say, look, we've got the major hospital associations, the nursing associations, the every single provider group and insurer in the state is putting out this incredible press release. Look at the supportive comments behind what you're doing, Governor, by doing this flu mask mandate, knowing that the reflected glory goes back to the people, the safety of the people. And so we went from 49% to 86% to over 95% annual immunizations for health care workers by mandating masks. And then that was copied by California and many other states as well. It's about choice. You know, it's about that one on one relationship with the union head and understanding his needs and understanding his members needs and really trying to encompass all of those needs, creating the policy window, running 100 miles an hour.
Henry Bair: [00:27:37] Well, thank you for sharing one of the high points of your career as health commissioner. I'm wondering if you can tell us a time when things did not go so well or some of the biggest challenges you faced as health commissioner?
Nirav Shah: [00:27:51] Yeah, what you hear are all the positive stories. You don't hear the 50 things that I tried and failed. It's those don't make the New York Times right. But I think the failures. For me. As I mentioned earlier, it's all about the individual connections to drive change. And what I learned over time is that I may have had ideas that I thought we needed to advance, but the timing wasn't right. The people weren't there, the stakeholders weren't ready. The the stars were not aligned. And so I have had so many failures. I probably have a list of all of them somewhere I'm happy to share with the podcast notes or something along those lines. But it's really about radical empathy, right? Every time I fail, it's because I didn't take into account a certain individual or a certain group's needs as you crafted a change package and ultimate solution. So early on, I made many more mistakes than later. You know, the example I'll give you is we had a medicaid reform package that ultimately saved $34 billion for New York State taxpayers over five years. Out of the 179 ideas, there was one idea that didn't make it that probably would have saved a ton of money and done well in terms of quality and safety. And that was related to medical malpractice reform. Of course, it was the right thing to do on many levels. The way it had been crafted was patient friendly. It was thoughtful. But then if the number one and two people in charge in the Senate and Assembly of New York State happened to be medical malpractice lawyers, or their practices have a big component of that, it's not going to go anywhere. And so that was kind of a blind spot. That was a big failure. And it was one of the big things that would save a lot of money and improve outcomes and improve New York as a very litigious state, improve a lot of things for many doctors as well. That was a big failure in hindsight. No surprise.
Tyler Johnson: [00:29:53] I'm curious. So just to be clear, first of all, do you now or have you in the last many years done any individual practice? Do you still see patients? And if so, what does that look like?
Nirav Shah: [00:30:05] Well, during COVID, Stanford called me back to see patients, and I was able to do video visits for a few months to help express care and urgent care. But I feel that at this point it's more for myself than it is for patients. I'm not I'm so involved in other things that it wouldn't be fair. I'm not reading all the journals every week to keep up, and at this point I'm board certified, but I'm not practicing.
Tyler Johnson: [00:30:30] Do you ever feel a draw? Like, do you do you wish that that was something that you could still do? Or do you feel like you've sort of wholly transitioned so that the impact that you've talked about making is made? Yes, indirectly. But I guess sort of that's where you feel like you can do the most good.
Nirav Shah: [00:30:49] Yeah, I'm pretty honest with myself about how bad I am at a lot of things. I think my wife is also honest with me about that. To the extent that patient care is something that brings a lot of joy and obviously we trained many years for it and I still love the science. And even studying for the boards and recertifying all of that is actually fun. I know that I can do much more. For example, I'm volunteering with the CDC. The work we're doing there is going to impact many more folks than I can ever do in a day's visits with a number of patients, and I'll do a better job. I think there too.
Tyler Johnson: [00:31:23] You know, one of the things that strikes me about the some of the stories that you've told where you've had great successes, like again, with the sepsis campaign, it makes it sound as if in the health care world, there's still a lot of low hanging fruit. Right? Not that that was easy, but it was a concrete, limited thing that you were able to identify that there was a on the spectrum, relatively simple intervention that when actually put into place, made a huge difference. Right. Is your sense that there is still a lot of that kind of low hanging fruit, that if we could just sort of universalize those sorts of programs, that we would be able to make huge advances in terms of whether it's response to sepsis or cancer diagnosis or screening or whatever. Or do you feel like we've kind of gotten most of the low hanging fruit and now we're left with things that are much more complicated?
Nirav Shah: [00:32:26] I think there's many low hanging fruit. It's about asking the right question. It's about getting the right folks to help you think about them better. For the last few years, I've been focused on what can we do to care for caregivers. My mom helping my father with dementia stay at home as opposed to being in an institution. The single mom caring for older adults, maybe in-laws or something, as well as kids at the same time, and many others. Today, the AARP estimates that over $500 billion with a B dollars of care equivalent are contributed by unpaid family caregivers. That's 2.5% of the GDP that's invisible. That's not part of the 17-18% we talk about in health care. And it has an incredible toll. And by creating a business case for caring for caregivers, where we are able to give them what they need, we help two people, the caregiver and the person they love and care for. That's an example of something where now the business case is being formulated. Some of our research work at the Clinical Excellence Research Center has used data from the Danish registries, entire countries worth of data on caregiving to show the true burden of caregivers and what what it means in terms of lost wages over a lifetime, medical spent, all of those data we now have for the first time. So then we can go back to the insurance companies and providers and saying, You're doing a bundle of care around a hip replacement. You're going to send Mr. Jones home one day after surgery to the arms of an unpaid family caregiver. Here's what you can do for the unpaid family caregiver, including Uber or Lyft rides, including meals, including ABCDFG, so the daughter who's flown in from 3000 miles away and is your unpaid non-unionized caregiver, instead of Mr. Jones staying in the hospital, you're actually taking care of both. And by the way, it'll prevent the readmission which you'll get dinged for and you'll have to pay for. This will cost a lot less, but do a lot more. And so those kinds of business cases around unpaid family caregivers is something that I'm working on today. There's many other examples, many in the areas of prevention exactly today where we have low hanging fruit, but it's about asking the right question in the right way so that it becomes lower hanging as opposed to something impossibly high on the top.
Henry Bair: [00:34:54] So you've already mentioned briefly a little of what you currently do. You mentioned volunteering for the CDC. You have also mentioned your work researching on caregiver support. Can you paint us a picture of what are some of the things that you do these days and how you spend your time?
Nirav Shah: [00:35:19] Well, I've been very lucky to have incredible bosses in all the work that I get to do. And so my approach has now become more a portfolio approach to the work I do. So, for example, I mentioned I'm here at Stanford as a senior scholar at Stanford, where we have an amazing fellowship program and the fellows have the chance to write these kinds of papers. We talked about the caring for caregivers work and many others that will dramatically lower the cost of care while improving quality and outcomes. That that's a big focus of my work. But then on the side, I'm also the chief medical officer of an at home diagnostics company. The blood work, x-rays, ultrasound at home, the largest one in the country. And I think that's going to help us as care moves to the home, leveraging technology, thinking about new workflows and lowering costs while improving quality is an absolute opportunity. And so care-at-home is a major area of emphasis of my work. And so that happens to be complementary to my work as well. I serve as an advisor at GSR Ventures, which is a VC firm in Palo Alto, and they're focused on AI and health care and many of their technology solutions -moving care to the home, making care much more efficient- is exactly in line.
Nirav Shah: [00:36:33] So they like the fact that I'm researching this. At the same time, I'm helpful to them. I serve as a board member at the John A. Hartford Foundation, where the focus is on improving outcomes and care for older adults. Things like age-friendly health systems in partnership with IHG and others have sprung from there. So it's about care for older adults and I think about care at home for older adults, safety, quality issues, etc. And then I'm a number of other boards. Steris is a company that is the largest infection prevention control company in the world. And as a trustee, I get to see the inner workings of how such a multinational company can actually improve quality safety and reduce infections and a few others. The CDC work is as an advisor to the director. Again, it's to my core of public health and its systems thinking. It's about improvement. It's all the things we know we need and I can apply there as well. So it may sound like a lot, but it's actually not much more than 40 hours a week, and it's because of the way that each group understands the value I bring, knowing what else I'm doing that allows that portfolio approach to work.
Tyler Johnson: [00:37:46] So if you were made the emperor of the United States for a week and you could just sort of the emperor of HHS and you could just implement any change you wanted, you didn't have to have sign off from anybody. You didn't have to get it through congressional committees. Nobody had to vote on it. You could just do a thing like what would be the top thing or the top two or three maybe related reforms that you think if we could just do this in American health care, everybody would be so much better off?
Nirav Shah: [00:38:18] I only get one thing. That's a tough one.
Tyler Johnson: [00:38:20] Three, three.
Nirav Shah: [00:38:21] Things. Okay, let me start. I think the easy one is improving transparency. The fact that most people don't know that CDC has 180+ individual funding lines based on a given congresspersons likes or dislikes. So why are we funding ALS research to the tune of 500 plus million dollars a year and sepsis research to the tune of $0 a year? These kinds of things people don't know. And so when you shine a big light on some of the inner workings, people start asking why? And what happens is, while as much as you'd like to plan for how things should be. You can't. The transparency forces positive externalities you can't plan for. When we published all the data for every cost and charge in New York State for every procedure. I got called into the board room saying, Why are you publishing this data that shows my hospital? We charge three times as much for a C-section as the one across the street with the same quality outcomes. Why are you publishing that?
Tyler Johnson: [00:39:29] Are you?
Nirav Shah: [00:39:30] And so I said, I'm just publishing the data. You can do something about it or it only costs $2 for a colonoscopy. Dr. Shah, your data are wrong. And like, obviously they're wrong. That's what they're reporting to us. Those data got fixed overnight. So if you can take the 15 minutes and wear Kevlar after transparency initiatives, a lot of good happens over time. And it's the gift that keeps on giving. People start asking more questions and more questions. And ultimately, that's actually what we did. That's how we were able to save money in Medicaid while improving quality and outcomes from 49th out of 50 in quality in the nation in our Medicaid program in New York State, by publishing where every cent went in Medicaid, we went up to 18th in just a few years. And that happened. That improvement in quality happened because people were saying, Do you really need to spend 18 hours of home care on an individual? They're helping with grocery shopping and other. Are we really spending that much money? And that's what the data show. And so people ask and I go, we actually need to change the way the funds flow and not spend it that way, but another way.
Nirav Shah: [00:40:38] So transparency is something that raises it's hard, but it raises all boats over time because it aligns the incentives it uncovers where all the cockroaches are hiding, and it does well. Another thing, bureaucracies have one size fits all to most things. And what I like to do is create more pipes, right? Instead of a there may be three ways to accept grant applications. There may be four four approaches to a given issue as opposed to one and bureaucrats over time because someone used a credit card the wrong way 27 years ago, no credit cards are allowed when you're paying the state. No, no, no, no. I understand that was then; let's figure out options. Right. So the optionality giving choice is something that bureaucrats do not very well. And if we can involve others and get those kinds of multiple pipes built out, all things get better as well. The bottlenecks go away and the speed of government improves.
Tyler Johnson: [00:41:43] Got it.
Henry Bair: [00:41:43] So towards the end of our conversations, we typically ask our guests about their advice for medical trainees or early clinicians. In this case, there are a lot of things that we could potentially ask about, so I'll try to keep it to one or two. So we'll start with you have served as a leader in both the public and the private sectors. I think that medicine as a career involves a lot of leadership. Sure, not everyone is going to be the health commissioner of a state, but even if you are a hospitalist and you're leading a team, even if you are a family physician, and it's just the relationship between you and the patient -guiding them and creating a care plan and helping them adhere to that- that takes leadership, too, right? So I would argue that all medical practitioners, no matter where they are, should be familiar with principles of leadership in this context or with all that being said, what advice do you have for early career clinicians and medical trainees on what being a good health care leader means?
Nirav Shah: [00:42:52] It's actually not that hard, I think. I keep it simple for myself. For me, it's really about working with really great people on important work. Why? Well, certainly you can work with people who are really smart, but just not very nice. I tend to avoid those people. I tend to favor the kind and thoughtful and caring people to work with and work for, because what that leads to is they're looking out for you in ways that you can't look out for yourself. They're creating skip level opportunities. They're pushing you into things that you think you have no business doing. And they're like, No, you're just going to do that. And so when I've succeeded, it's because of phenomenal bosses like Marc Gourevitch at NYU, like Ben Chu at Kaiser, like many others through my career, who make me a better version of myself, right. Who also help focus the work on great work. They will have a different perspective from where they sit. And so you may think that in front of me, I need to work on this problem because I can solve it. I know this, and they'll put a few tweaks or modifications on it to suddenly make it work across the entire hospital or across a multi hospital system or elsewhere. And they'll make you speak about it at the right speaking engagement. They'll make you publish on it at the same time. And so that that that combination of working for really great people on really important work. It's actually very satisfying. It's what helps you grow as well. So on many levels. All of us have to be leaders where we are, and this is an easy way to be a leader is to just work with really great people on really important work. It's really that simple in my mind.
Henry Bair: [00:44:29] I think when over the course of this conversation, what has really stood out to us is the sheer diversity of the things that you have done. And yet it makes sense, right? As you tell us what you have done, you are able to connect the dots. And, you know, even with the most recent even with the recent question I asked about what do you currently do now, you paint this tapestry of a lot of different kinds of things, but then you're able to draw a common thread, a theme through all of those things. So I'm wondering what advice do you have for medical trainees who are about to embark on their careers and they can see all these different kinds of things they can do. What advice do you have for them about engaging in the most meaningful work for them?
Nirav Shah: [00:45:23] It starts with being honest with yourself, Right? What are you good at? What are you not good at? And optimizing for you. You can mitigate some of your weaknesses, but you're not going to be the top 10%. On the other hand, double down on your strengths and you will make an impact. So I know, for example, that I get excited by data and I'm interested in quality and safety. And so those things suffuse everything I do somehow. By the way, hindsight's 20/20. What you heard is after-the-fact stitching it together. But I stitched it together also because I was actually thinking on paper and saying, I know I want to do these kinds of work and I don't want to do the following kinds of work. That allows you to then actually have a narrative over a course of a life. So I think for trainees, the easy stuff is you're surrounded by incredible, great folks, just even on the wards. Find those great people and spend time with them, learn about them, care about them, ask them what you should be doing, knowing yourself and knowing what you're good at and sharing that with them.
Nirav Shah: [00:46:33] That's the easiest way to get started on leading a meaningful life. And frankly, as much as you like to plan and I am a planner, I have one year, three year, five year goals, plans, all of this for myself, for my kids, all of that. To the extent that I change my plans all the time because of opportunities as they come up, I never plan to be health commissioner and move my family to Albany and take a giant pay cut and not see my kids. And yet that was the right thing for those few years. I didn't plan to move across the country and join a health plan and work on the insurance side of things. But again, it was a skip-level opportunity where I could work with someone great and I knew that would lead to great things. So it's kind of contradictory advice. Be a planner, right? Think on paper, know yourself, be honest, and at the same time be willing to change your plans in real time based on the opportunities in front of you.
Henry Bair: [00:47:29] Well, with that, we want to thank you for your time and for your generosity and sharing your story and your insights. It was a true privilege.
Nirav Shah: [00:47:35] Henry, thank you.
Henry Bair: [00:47:39] Thank you for joining our conversation on this week's episode of The Doctor's Art. You can find program, notes and transcripts of all episodes at the doctors art dot com. If you enjoyed the episode, please subscribe, rate and review our show available for free on Spotify, Apple Podcasts, or wherever you get your podcasts.
Tyler Johnson: [00:47:58] We also encourage you to share the podcast with any friends or colleagues who you think might enjoy the program. And if you know of a doctor, patient or anyone working in health care who would love to explore meaning in medicine with us on the show. Feel free to leave a suggestion in the comments.
Henry Bair: [00:48:12] I'm Henry Bair.
Tyler Johnson: [00:48:13] And I'm Tyler Johnson. We hope you can join us next time. Until then, be well.