The Author: Paul Pender, MD

Transcript

[0:00] And too often in this country, patients are flying solo and they need an advocate.
And it used to be the doctor was the patient’s advocate, whether it’s with insurance companies or third parties or what have you.
And doctor’s time has become so contracted that they also need to be supported.
Paging Dr. Cook. Paging Dr. Cook. Dr. Cook, you’re wanted in the OR. Dr. Cook, you’re wanted in the OR.

[0:32] Music.

[0:56] Hello, everyone, and welcome to Prescription for Success. I’m Dr. Randy Cook, your host for the podcast, which is a production of MD Coaches, providing leadership and executive coaching for physicians by physicians.
To overcome burnout, transition your career, develop as a leader or whatever your goal might be. Visit MD Coaches on the web at MyMDCoaches.com because you’re not in this alone. And don’t forget that CME credit is available when you listen with us. Just look for CMFI in the show notes to learn how. Well, we are welcoming back one of our prior guests to Prescription for Success today. When we last talked, Dr. Paul Pender had just closed his ophthalmology practice after 38 years.
But he certainly did not take a seat and become a spectator, quite the opposite.
He’s about to publish his second book, which we’ll talk about today, in addition to some other projects that he has underway.

[2:01] So let’s hear my conversation with Dr. Paul Pender. I am really looking forward to a new conversation today with Dr. Paul Pender, who we have had on RX for Success in the past.
I had a very interesting story to tell back then. Some new things have happened for Paul, and we’re delighted to have you back, Paul. Welcome back to the show.
Hey, thanks for having me, Randy. I really appreciate it.
We got a number of things that we would like to get into, You and I, we were almost precise contemporaries during our practice and at the time that we retired and so forth.
Kind of interested, very interested in fact, in how you’re handling retirement. Obviously, I’m going to be measuring my own management of retirement by hearing what you have to say.
So let’s get into this thing. The first thing for you in retirement was that you became.

[3:09] A really successful author. And I want to talk a little bit about your first book, Rebuilding Trust in Healthcare, a Doctor’s Prescription for Post-Pandemic America. We talked about this one about a year and a half or so ago when you were last on the show.
And now that you’ve had a chance to reflect on that message and get some feedback from your readers, have you learned anything about how we came to lose trust in the healthcare system?

[3:37] Oh, I think I’ve learned quite a bit and that’s really what the book was about.
I can also say this hasn’t made it to the New York Times bestsellers list yet.
So any promotion you can do for me, Randy, I’d appreciate it.
No I wrote it during the lockdown, COVID-19 pandemic.
And at that point, I realized that I wanted to look at why distrust was part of healthcare and how I could sort of unwrap it and deal with the various components because it wasn’t just about internal forces or the doctor-patient relationship.
It was about external forces as well. And then combine that with a pandemic.
And I realized that I wanted to sort of approach this like you’d present a case at Grand Rounds.
Why was there distrust? Let’s analyze it sort of according to what physicians do when they break it down by history, findings, social history, an examination, as well as an assessment and plan.
And so that was really the outline of the book.
But again, I published it in September of 2020 before there were any vaccines.

[5:03] So it was a book that tried to capture not only the distress that people were feeling in healthcare, but also to provide some element of hope.

[5:18] And I alluded to the possibility of vaccines in the book, but it really wasn’t until late December, I think, that vaccines were finally available.
And so some of this in the book was aspirational, and then we learned later that vaccines were effective. There were still people that were hesitant to try it for various reasons.
And I wanted to sort of not have to deal with the political.
Controversy, but I did want to talk about trust was still something that we needed.
So I added that to my blog.
Then as I looked at my blog posts, I started to organize them according to several themes.
That’s how the new book, Standing Up, and Speaking Out for Patients and Doctors, how that started.

[6:13] Started. So you know, I’m really interested. You mentioned that you apparently decided to write the last book at the time of onset of the pandemic. Do you think there would have been a book? Have there been no pandemic? There may have been a book, but it wouldn’t have had the same impact, I think, because I think what we’ve discovered is how much healthcare has changed with the pandemic.
I mean, just look at something like telehealth.
It was an anomaly before the pandemic, and now it’s kind of normal operating procedure.
People have telehealth visits.
Doctors can be compensated for them. Patients who are in remote locations can actually get care and direction by way of their mobile device. So a lot has happened since the pandemic, some good, some bad.
Yeah.
That that will always be evolving, I’m sure. There’s a new book now, Standing Up and Speaking Out for Patients and Doctors, First Steps Toward Focused Healthcare Solutions.

[7:21] Was the nidus of this new one taking shape during the writing of Rebuilding Trust, or did it come to you later?
It came to me later. In 2022, I started to just try to get the 30,000 foot view of the work that I was doing and I started to think about different themes for the blog posts that I’ve submitted or if I looked at some of the essays I sent to KevinMD.

[7:53] And were published, they sort of took on kind of a momentum of their own.
And because I had one essay that was actually read by the CEO of a healthcare startup, That’s.
Really how he contacted me having read this essay. And the next thing I know, That’s interesting.
We start to communicate and I was asked to become the director of digital health communications for this startup. And we’ll talk about the company in a little later.
Yeah, I really want to get into the details of that a little bit later on.
But one thing that I would like for you to expound upon just a little bit now, The title of the book is Standing Up and Speaking Out for Patients and Doctors.
And I have a feeling that doctors won’t have any problem buying into that title at all. But for, people who are not physicians, a lot of people are going to say, why do doctors need somebody to stand up for them? You know, don’t they kind of have it made? You know that that’s an attitude that a lot of people harbor either rightly or wrongly for a variety of reasons.
But why don’t you just go ahead and tell us, why do you think that doctors need someone to stand up for them? Well, I think they’re getting crushed. I think they’re getting crushed.

[9:18] Think about the primary care doc who has to see patients at an accelerated rate because his practice was purchased by a hospital or private equity and now has to crank up patients, also has to document everything for billing purposes and then is handling portal questions that need responses immediately. Well he’s not just a physician anymore, he’s a profit center. He or she is being bludgeoned by the.

[9:48] System right now and so we can get into more detail about what’s happened to physicians and burnout surveys and all the rest. But I wrote the book because it’s about the doctor-patient relationship. To me, that’s sacred. And I think you can stand up for patients and it’s a pretty easy call because unless you are connected to the medical field, you are on the outside looking in. And too often in this country, patients are flying solo and they need an advocate.
And it used to be the doctor was the patient’s advocate, whether it’s with insurance companies or third parties or what have you.
And doctors’ time has become so contracted that they also need to be supported.
And you’ve done a really good job of highlighting exactly that phenomenon and that reality that physicians are practicing in nowadays.
One of the essays that really caught my eye was one entitled, Why Perfectionists in Medicine Need to Practice Compassion.
Do you think the compassion of medicine occasionally gets lost in the midst of perfection?
Is that where that came from?

[11:04] Yeah, and I think maybe you picked up another essay that wasn’t in the book, but I’ll try to address that. I think we enter the medical field in a very competitive environment, don’t we?
And there is this need to feel like you’re giving your best all the time, and you want to feel like you’re giving your best all the time, but we don’t always do our best all the time.
And I think you have to be compassionate because even with your best effort, sometimes you setbacks in that Kevin MDSA, one of the subjects I raised was with cataract surgery.
It goes so well for so many people so often that you start to get complacent.
I used to say to myself, if you start taking this for granted, you’re going to have something bad happen to you.
If you have a complication, you’ve got to be prepared to be humble enough to say, okay, I need to learn from this.
I need to express to the patient, we’re going to get you through this.

[12:11] And you can’t abandon the patient. I mean, the patient wants to know that even though this is a setback, that you are still in their corner and you’re still going to find a way to help get them through that.
So that will help relieve some of the anxiety.
The perfectionism is a burden for a lot of people, but if you don’t have compassion for those times when things don’t work out the way you want to, then you can lose that very important element of trust that you had with the patient.
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[13:56] For a free consultation. And now, let’s get back to our interview.
How do you think a physician goes about making sure that their compassion comes across?
Dr. Cedric C. Johnson I think you have to make eye contact. To me, it was I put a hand on someone’s shoulder when I greeted them while I shook their hand. I mean, this was, again, since I retired just before the pandemic, hugs and shaking hands were still socially acceptable. So if I put my hand hand on the shoulder of a patient who I thought looked ill or had lost weight, I could feel, their scapula through their clothing. And I knew that something was happening in their life. And so.

[14:46] We would, it was an opportunity to sort of break the ice and say, this must be stuff going on in your life. And you wouldn’t have to do this on every patient, but you had to be prepared for those people that needed that boost, you know, that professional boost that we gave as physicians.
And you know, Paul, what’s coming across to me so profoundly in what you’re talking about right now is that you are an ophthalmologist. Your patients are almost always examined in a chair that is specialized to position them appropriately in front of refraction equipment, and yet you clearly made sure that you took the time to make physical contact with the patient.
Do you think that’s common among ophthalmologists or what do you think?
I think they are probably under the same pressures we talked about.
The same pressures that apply to primary care doctors also apply to specialists.
You still want to make eye contact and you still want to make sure that they understand you’re on their side.
The type of arrangements for an exam are different.
And we get to do our exam in ophthalmology with the patient’s clothes on, which is an advantage in some ways. So I think the patient may not feel quite as vulnerable, but I also think that they fear.

[16:13] Losing vision. The fear of blindness is one of those fundamental fears, I think. And so, it’s our job to sort of set, you know, be able to temper some of those fears and to be able to have conversations with the patient so that they know that we are going to help them get through whatever problem they have. So, that seems to be universal among physicians.
It’s, you know, we’re going to address issues that are important to you and what you need right at this very moment.
Another title that really caught my eye in the book, at least I think it was in the book, now I might have lifted this one out of Kevin M.D. as well, but there’s one entitled Caught in the Middle, How Health Insurance Companies Influence Cancer Drug Selection.
Can you explain that one a bit? Yeah, that’s another Kevin M.D. title.
And you know, I think I’m not an oncologist, but I’ve realized that I’ve read enough stories that have impressed me when certain medications that the doctor is recommending are either.

[17:18] Not in the formulary for that health plan or they get shifted to a cheaper drug. And I think, the bottom line is that it shouldn’t be health insurance companies or pharmacy benefits managers that are making the call. The doc ought to be the one making the call for what’s the best drug for that patient in that situation. So that’s the summary of my 500 word essay. There are certain fundamental principles I think that should be followed and really it’s the doc that’s the doc who should be making the call. When I read a story about a woman, this is a health reporter from the Washington Post whose son had a, I think, juvenile rheumatoid arthritis but wasn’t responding to normal medications and then they found one that would but then the insurance company was giving her a hard time and wanted the child on a different drug first in step therapy, you know, like try this one, if that doesn’t work, we move on to the more expensive one, da da da da.
But in fact, the family realized that they had already gone through some of the preliminary steps with drugs and that they needed to get to the defined drug that was going to do the best job.
But that took jumping through so many hoops that even this health reporter for the Washington post.

[18:41] And she was someone who understood what it was like from the insurance side, not wanting to spend too much money on drugs without a good reason.
And so put up all these other things like pre-authorization to impede the process.
She understood what was going on.
And here’s someone on the, if you will, as a healthcare reporter, was on the inside.

[19:05] But still couldn’t really get her story across.
So when she wrote this piece, I think it was either in Vanity Fair or another well-respected publication.
It was an eye-opener for me and that’s something that I would then write an essay about that sort of situation.
So what I realized is that this pre-authorization is substituting for physician judgment.
Is essentially a delaying tactic.
And oftentimes it leads to more complicated things like peer-to-peer review.

[19:44] But unfortunately, when the doctor who’s advocating for his or her patient is on the conference call with someone who’s not even of the same specialty as the condition that the patient is suffering from, something’s wrong with that system.
You bet. And you know, I hate to give the impression of being a bit paranoid, but I’m convinced that that practice is designed for no other purpose other than to slow things down. My experience with it has been that eventually you do what you recommended to begin with, but it just takes up a tremendous amount of time. And for them, time is money.
And for the doctor, it’s additional time taken away from what could be good patient care.
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[21:36] We’ll get back to our interview in just a moment. But right now I want to tell you a little bit about Physician Outlook.
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[22:39] And now let’s get back to today’s interview. Perhaps you could tell me about one or two of the episodes in the book that you thought, were most meaningful. Can you do that?
Yeah, I think there’s a chapter in the e-book and it’s called Getting Messy in the Game of Healthcare. And it was really a quote from Larry Hightower, the CEO of the company that I advise.
And it really was that, you know, you can’t stand on the sidelines and you need to be able to get dirty in the game if you’re trying to change it. And so from the perspective of the Goodyear blimp, would you still even know what was happening on the field if you didn’t know what the rules were?
A lot of people have been writing in the blimp involuntarily and not really aware of how the rules of the game have changed. Healthcare has been in the process of changing now whether we like it or not. I do feel like one of the important elements from that chapter really had to do with, I think it’s what is the best school.

[23:55] You and I would talk about what it was like in the old school and how there was respect for physicians.
Well, what is the best school? It combines tech with the values that attracted us to health care in the first place.
And so the fact is that, yes, we’re going to play this game.
We’re going to work on our company.
We’re going to try to build it up. We’re going to let people know that there are alternatives.
And if I just use one example, you know, pre-authorization is unnecessary if you hold physicians accountable for their…

[24:30] Decisions. And I believe that when physicians can collaborate in an effective way for the best care of the patient, and they can use technology to sort of see what that patient’s health journey has been, then they’re going to have an advantage. And you don’t have to put in these barriers like like pre-authorization to be able to expedite care.
So I think that the best school is going to combine those virtues that we think are part of being a healthcare worker with technology that’s going to have the big view, the view of not only this patient, but how this patient may compare to similar patients in a population-based approach.
Now, you do need large cohorts of patients that share some of the same demographics, lab values, what have you, but you should be able to see what trends are like.
So the ultimate goal, I think, is to be able to predict and prevent health problems.
We should be more in the business of healthcare maintenance rather than healthcare delivery.

[25:47] If I’m understanding you correctly.
I think certainly we can look at things that add extra cost to the system and then try to find what brings value to the system.
One of the things that brings added cost is I believe there are going to be situations where if the patient hasn’t had decent primary care, that they show up at the emergency room were the urgent care center and add cost to the entire system. So I think one of the things that I may even mention in the first book, Rebuilding Trust in Healthcare, was an example from Thomas Jefferson University where their employees and they had, you know, a couple thousand or more employees in their health plan, if they just had a telehealth quick screening before they went to the emergency room, not only did they get appropriate care, they also didn’t have to incur so many emergency room costs and they saved a million dollars in the first year just by adding this step where there’s a patient advocate that could, usually a nurse that was doing the screening call, but it was a way of being able to sort of set them in the right direction.

[27:06] And if a patient who isn’t part of the medical field is concerned, anxious, doesn’t know what to do or where to go, having that kind of direction navigational ability.

[27:21] Was really important to their health system. And I think that is something that I believe is going to be an important element of the company that I’m working with. And that’s exactly what I want to, get as deeply in as we can. Your very appropriate interest in the relationship between patients and physicians has clearly made you much more acutely aware of how the current realities of health care frequently kind of get in the way of that relationship.
In fact, from what I’m hearing from you, it sounds like that you’re even more acutely aware of it now than you were back when you were practicing.
But I gather that it’s that understanding of that particular difficulty, the roadblocks to good care, particularly good preventive care, are a problem.
And I’m assuming that your interest along those lines had something to do with your interest in this new company called Vextra, which nobody knows anything about because there’s not a lot of details out there on the internet.
But I’m hoping that you’ll tell us a little more about Vextra. That’s right.

[28:42] I think I can give you… Well, tell us about Vextra.
All right. I can give you the background. So the CEO reads my essay, he contacts me, how we start talking about his idea for a better healthcare system that is a narrower focus. So the subtitle of the book I’m about to launch today with your interview, Randy, is basically the first steps toward a focused healthcare solution.
So if you look at employer sponsored health benefits, it’s a large part of the workforce that has access to employer sponsored health benefits, but we’re talking about a middle market here where they are underserved.
They’re not getting the kind of attention that Amazon is going to give some of their bigger customers.
But in the middle market between 200 and 2000 employees, that’s a fair amount.
Of business that we think that we can approach. It’s a market that is right for disruption because they’ve relied on the legacy health insurance companies and they’ve also relied on traditional pharmacy benefits managers that are essentially glorified middlemen that extract a lot of the profits or if you will, the flow of money.

[30:12] You had on your program Dr. Mass, I think is her name. Dr. Marion Mass.
Mass, who- She is probably the world’s expert on PDMs.
Yeah. She also has taken on a much larger focus, including the entire National Piggy Bank.
What our focus is on this middle market of employers who are desperate to find ways of adding value to their benefits.
One, they want to keep good employees around.

[30:43] Two, they want to know what their two costs are for their pharmacy benefit, and that hasn’t even been available to them.
They’ve been essentially blocked from understanding what the two costs of the medications are that they’re offering through their prescription drug plan.
And what Vextra Health is doing is that not only are they working to partner with tech platforms that can dig deeply into the patient’s health data with permission, but also look at ways to add value by not charging commissions on prescription drugs.
And that’s an important feature. When you think about it, if you have just a handling cost, a pass-through cost, and maybe a cost of administrative work, but not commissions on drugs, then you’re not trying to steal money from the system.
The whole idea about commissions, whether it’s commissions that the health insurance companies get or that pharmacy benefits managers get.

[31:49] You know, these are outrageous in terms of the entire cost of healthcare. So I think what Larry Hightower and his crew professionals that have a lot of experience in healthcare and as third party administrators for a number of these larger healthcare systems, we call them the Bucas, as you know, Bucas, United Healthcare, Cigna and Aetna. So, you know, what he’s learned from having to deal with these people and these systems is that there’s a lot of hidden cost.
I think when you have an open source and you have a well-defined approach to managing health benefits that doesn’t involve some of the traditional players, that you can bring added.

[32:41] Value.
So one of the things that we have done in the company is recruit people who have significant amount of experience in value-based care.
This started out in the Midwest with some of the major employers out there with a health system that has been able to reduce the year-to-year expenses for these employers but still maintain high-quality care.
So the blueprint is there. Now it’s, as I said before we started the actual recording, you know, when you’re a startup, you take the good things that you’ve learned from experience and you put it into a new system and try to make that work.
We’ve gone from the crawl stage to the walking stage. And before we can run, there’s more that we have to do.
But I think that this is a much better approach. It’s focused.
On middle market employers and their health benefits that are covered under.

[33:42] ERISA, which is the law that was passed in 1974 that allows employers to customize their health plans. So I think that this is going to offer something that’s kind of scaled to what we want to be able to do and to maintain health care kind of on the local level with local employers and make that work. And I think it’s an area that represents a fairly large market. It just hasn’t really been able to take advantage of resources. And so that’s something that we want to be able to provide for employers. Yeah, I should think it would be terrific opportunity. And can you give us an idea about the stage of development where we are with Vextra at this point? Or do they actually have.

[34:31] Subscribers and providers at this point? Or where in the process is this enterprise?
I think it’s already gone through proof of concept with approximately 19 states and a number of medical practices that they managed for their healthcare benefits that were large medical practices and they certainly made connections with a lot of the entrepreneur physician owners of these practices to be able to understand what their needs are. And they also were able to land a two-year contract with a major group called the Georgia Bankers Association with about 20,000 lives that they’re helping to manage and to be essentially on the cusp of making other arrangements that allow the company to grow and benefit from their experience. So Larry likes to refer to some of this work as a clinical trial.
And from the experience you gain in the small scale, you should be able to apply it to a larger population.
Well, this sounds very exciting, and I suspect that you’re very excited to be a part of the whole building process.
And I can’t wait to see how it develops.

[36:01] Well, I am excited. I’ll also say that this has been a real education for me. Yeah, a bit.
I’ve read a lot of stuff. I’ve read articles, books, and all this.
A lot of it really has to do with preparing you for the kinds of questions that need to be asked from a business point of view.
I think my role with the company is to make sure that the physician’s voice is being heard.
And I bet you will. You are as good a physician advocate as I think I have ever met, and Vextra is very fortunate to have you.

[36:40] Well, thank you. Thank you so much. Thank you so much.
Well, listen, I’ve really enjoyed talking to you again. Before we get out of here, I want to give you an opportunity to tell the audience about both your books and where they can be found. You want to go ahead and give us that information?
Sure. I think they’re both available through Amazon and the ebook is going to be available It’s on Amazon, Barnes & Noble, Apple Books, and Google Play.
It’s called Standing Up and Speaking Out.
For patients and doctors, first steps toward focused healthcare solutions. The original book was published in 2020, as I said, before we even knew how the pandemic was going to expand and.

[37:30] Have vaccines available. And what’s really amazing is that we’ve learned that so many different variations, I guess, mutations of this coronavirus have occurred. And you could make the analogy that healthcare is kind of going in the same same direction. It’s you know there’s so much consolidation that’s taking place that we want to make sure that physicians and patients that bond is what is really has to be the driving force for any kind of healthcare reform. And I am excited about being associated with a company that is actually respectful of that and working to make that a a very viable alternative.
Yeah, I’ll bet you are. We’ve been looking for that company for a very long time.
And the final thing we need to do is make sure we give you an opportunity to tell our audience where they can find you.
OK, I think if they would like to write to me, my email is paul at paulpendermd.com.
And I will make available to people that write to me excerpts from the book if they’d like to see that before they make some purchasing decision.

[38:47] But the way that I think this will evolve is that people will continue to read my posts either on my blog or some of these other social media platforms.
And they can also write to me in replies if they just click on my name.
And you want to give us the web address for that really nice website that you have for your blog. The website is paulpendermd.com. Pretty easy to remember.
Yeah. Paul, I really enjoy talking with you every time we get together.
And I enjoy talking with you. And, Randy, thank you so much for inviting me to the program.

[39:25] Well, it’s been a pleasure and we might just want to have you back when Vextra is bigger and more recognizable and I’m looking forward to seeing what kind of success they might be in for.
Well, that’d be great. Look forward to it.

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