The Integrated Practice Builder: Cheng Ruan, MD

[0:26] Paging dr. cook paging dr. cook dr. cook you’re wanted in the OR.

[0:36] Music.

[1:00] 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,
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[1:38] Well my guest today has been with us on our eggs for success in the past
he’s a respected thought leader and the field of Integrative Medicine he has an online workshop for building a successful Integrative Medicine practice and we invited him back to talk with us in more detail about that project,
so let’s hear my conversation with dr. Chang rwan.

[2:02] Music.

[2:07] Welcome to prescription for Success everybody I’m very excited today because we’re giving Today’s show a little bit of a.
Different Twist and we’re going to do that by going back to visit an old friend
dr. Chang Wan welcome back to the show my friend good to talk to you thanks very much great to talk to you and I will go ahead and give myself a shame Shameless plug before I get into your Shameless,
plug-in that is I would encourage our listeners who haven’t heard the interview that I did with you,
I don’t remember how long ago it was but I know that it was episode number 72
you can learn a great deal about doctor wine and the origins of his interest in integrative medicine and that conversation and I encourage you to take advantage of that if you will
but today we’re just going to talk about,
some fresh things Chang I know that you’re very excited to be in the midst I guess it’s fair to say you’re in the midst of the launch of Integrative,
practice Builder is actually been underway.
About five months you want to start with definitions what’s that all about yeah let’s talk about that for a second you know I think.
Whenever we’re inspired to do something and we go all in you know it’s the right thing to do when you just kind of working tirelessly but you still end up with a lot of energy at the end and so this is one of those things you know.

[3:35] And I’m sure the people listening to this you always felt about that about something in your life something that gets to juices going,
so the integrative practice Builder is not just integrative medicine but it’s for people who want to integrate their values into the practice of Medicine.
And that’s the definition of integrating integrative medicine it’s not a style of medicine it’s what values can we.
Give to our patients as practitioners what’s uses us what are we passionate about and how do you integrate that from a creative side.
Into your actual clinical practice I’ll give examples so,
me personally I’m very much into neuropsych into mindset into mindfulness and meditation and breathing.

[4:26] And so that’s just something that’s part of my culture Buddhist as part of my culture.
And well I don’t teach religion that do teach the methodology in which we can utilize that for physiologic benefit to the patient’s so you know majority of my practice is now focused more on neuropsychiatry even though I’m an internal medicine board certified
so that’s just an example hey I want to integrate the things that I care about that I do myself and how do we how do you
how many funnel that into business structures and that’s what Integrative Medicine really is that make sense,
yeah it does and I’m interested.
And again to restate for the audience you’re actually trained as an internist what you’re doing now is although.

[5:18] And you can correct me if I’m misrepresenting you here but I think it’s certainly correlated to internal medicine but yet it has some substantial differences and I’m wondering.

[5:32] When you knew that’s where you wanted to go where did you spot the motivation went how did you know that it was time to
do something different can you tell us about that that personal experience at all,
yeah so my mother’s an acupuncturist and herbalist my daddy’s MD phds one the science side of things so.
I’ve always been integrated grown up,
and so the direction was always there the value was always there to to create that sort of bridge between the worlds.
The there’s several aha moments I think in my life that allowed me to kind of progress in this path and doing the things that I’m doing and one of them is recognizing that.

[6:22] Medicine is a bit over labeled you know whether its internal medicine or neurology or something like that and there’s a lot of labeling that’s associated and that that
you know has his own group of values that that that doctors have,
and I never realized that until you know got into four years into clinical practice and student
your Internal Medicine stuff inpatient outpatient hospice etc etc,
that I realized that you know when people talk to me especially when patients talk to me,
they don’t really expect me to say the things that I say you know someone comes in to the to the office I don’t really say hey how can I help you I was like you know how would you like me to help you on your journey today.
You know cut throws him off a little bit
images look at me only huh no one’s asked me that before and what’s great if he is that the creases sort of subconscious process with a patients become their own Heroes they’re not expecting me to be their hero right
and that creates a very large and meaningful conversations I’ve always really had,
um the way that medicine sits right now the way that’s designed right now is not necessarily designed for that little conversation and then we’ll that opens up to.
Um until very recently really probably 20 21 is the first time.
Based on the new CPT reimbursement changes and we’re going from.

[7:49] From a value-based care model sorry from a volume based care model to a value-based care model,
and also just insurance reimbursement General it’s a lot of it’s changed over in the biggest change was 20 21 so I see a bright light.
So we’re stepping into this age and that’s starting Radiology by the way so we’re stepping to this age where there’s a lot of changes happening that’s faster than what’s taught in medical school residency and fellowship.
Well it’s about time somebody started thinking that way because.

[8:23] You know I had a career of 44 years in practice and things were always happening faster than we could actually bring them into our.
Into our own practice I actually I remember speaking of your last interview I talked a little bit about how we talked about.

[8:48] Type 2 diabetes back in the when was I there in the mid-70s and it didn’t actually have that name.

[9:01] We didn’t really know that it was something totally different from what we had recognized as diabetes and so what you’re telling me is that.

[9:13] This is not a recognition so much of a.
Pathologic or a change in the way we see pathology or physiology it’s a the way we deliver the serve service am I,
getting close yeah I think we’re going back in time actually before there was an FDA before there were a lot of bureaucracy you know there was a doctor and a patient and every doctor is a holistic doctor
you know we gotta go back in time right and just seen my my grandfather and people that I saw the past it’s just like,
you know medicine has changed those become so systematic and it look at let’s look at electronic medical records right.
These are data mining tools that have completely changed the way that we practice,
Madison there’s a lot of policing that’s there that’s corrupted the the communication between the doctor and the patient just because of what we thought was valuable.
And so if you look at outcomes for example right so patient outcomes which is what I always like to stand on.

[10:20] The the patients with the best outcomes are the ones with the most touch points so the most Communications right.
And that’s true for anyone with you know metastatic lung cancer and they have a lot more touch points for example and there are hospice and lo and behold they actually live longer in those people who,
go under aggressive care and some types of cancer is right,
we see those people with concussive injuries and traumatic brain injuries and Military vets well guess which population,
is the least likely to commit suicide as a patient with the most number of touch points right,
it’s all about communication and touchpoints what we’re starting to realize is that the way that we communicate with each other and with patients,
is what actually drives the outcomes more than the medicines do so I mean that’s not surprising and that’s if our to talk to.
You know my grandpa in the 1950s and he’s like duh yeah that’s that’s of course you know and so the humanistic side of Medicine,
I think it’s we value it less because you know me I you know me training in medical school and residency.

[11:31] Or value was clinical outcomes in terms of numbers in terms of mortality and morbidity.
But what about the quality of life and what about you know patient autonomy right choices that are there right.
And so that’s what really dug me really deep into the integrative practice side.
And I think that you know sharing that with the world is something that I really cherish.

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[13:13] I don’t know if you did it purposely or not but you have invited me an area of deep Phyllis deep philosophic discussion I hope you’re ready to go there now you mentioned,
that the way that the medical record changed and it made me think of.
Again my own experience and my earliest experiences as a medical student I remember many many late nights
the middle of the night when there was nothing to interrupt me there was no conference to attend you no no presentation to give it was just,
me trying to work up a patient and one of the way that you’d one of the ways that you did that,
a long long time ago in a world Far Far Away was to go down to the medical records department and asked the clerk to give you the records on a particular patient and I discovered that.
Within those medical records there would be dictated history and physical operative summaries consultation reports,
and other Communications that had been dictated in,
plain English into the medical record and frankly I think that I learned much more from Reading those.

[14:35] Dictated notes many of which were dictated by,
the grates of the Ira’s before me the tensley Harrison’s and the champ lions and people of that sort.

[14:50] I don’t think that.
That kind of record keeping well I know that that kind of record-keeping doesn’t exist anymore but I don’t think there is a way for current day medical students and residents.
To have that experience do you think.
They will ever have that again will we we record thoughts and a way that we can go back and see how people thought many years before us or not,
absolutely so what you’re talking about is I looking at dictations and the thought process that comes rather than looking at,
a pre-templated format.
That you can just drag into the template and and you know right out some structure Fields right it’s almost mathematical you know it’s left right instead of right brain right and so.
And so we’re seeing a lot of that because of the medical record you know templates are they are important because they do save time but the same time.
It takes out the the actual linear thought process that really occurs.
Now you know you have Hospital Systems who have Physicians dictations which I used to do in.
And now you have scribes that can do it as an outpatient so I think we are getting to that and then we actually use artificial intelligence.

[16:14] Call Deep scribe.
Where it translates the conversation between me and the patient I mean the robots listening to us and it’s writing out in a NLP format.

[16:25] Natural natural natural language processing format onto the actual note.
And so we’re getting there but it’s costly right it’s very expensive to do and especially practicing Integrative Medicine,
where if someone is coming in and we’re talking about medical stuff but hey if their spouse passed away if they have something family in their lives I want that to be captured as well,
and I want to relate that to how that has translated into the physical health right,
yeah so these are called bio social factors site bile cycle social factors,
so the word biopsychosocial I didn’t make up it’s actually in the language of CMS the center for Medicare and Medicaid services,
and yes and it’s in the language of CPT codes there’s Ashley reimbursable CPT codes.
That now are designated to tease out these biosocial cycle factors how about that and you know what no one knows about them right,
but they exist because the reason that they exist is because they used to exist in neuropsychiatry but now they exist within primary care and other Medical Specialties Orthopedics and Pain Management.
But our people utilizing these CPT codes and the answer is no is because no one’s formally educated them on any of this stuff.

[17:46] So the obsession here is hey you want to be a good doctor you’re probably already practicing.
In a way where the CPT codes already described what you do and you just have to be able to document and Bill for them.
And so that’s that’s that’s an art as much as it is a science to to examine this you know when we started.
Engineering are CPT workflows in 2017 there wasn’t as many as it is right now.
But you know I do love so deep into how these codes were.
Were created and how was this supposed to be utilized and the gray areas that are here and there.
I realized that there’s does not consistency there’s no consistent way of telling the entire United States all the doctors the USA we got this going on now.
And even if they even if there was even if there’s like a press release which there isn’t.
The language is so like intellectual that it’s lost on people you know so so there’s no Bridge there and I wanted to be that bridge was like hey you know what their CPC Beauty goes out right now.
If you call a patient about a result the next day.

[19:04] Okay that’s that’s reimbursable you know bill for your phone calls if if you are sending a patient a text message or an email.
Right and you spend a lot of time over over over the last seven days all your conglomerate time over the last seven days is billable now if patient sends you a picture of their foot and ask you Doc is this an ulcer,
right that picture is billable as well as their text messages so this to billable CB.

[19:31] So the problem here is that a lot has changed in the last few years especially in 2021 to 2022.
That allows for that communication to be reimbursed and you know money really drives Behavior so we’re able to,
change the way that we want to practice medicine based on the way that we do it we have to know what you know what are we going to get paid for right and so from yeah so from a revenue side,
dollar for dollar is actually more profitable to have short phone calls with patients right and it just schedule that for an entire day,
you know and is more convenient for the patients more convenient for you you don’t have to burn your staff then seeing the patients in person on the E&M visit,
significantly more profitable right and so,
and so now it’s like wow we got this technology we got this thing called a phone we have text messaging we have emails we have secure messaging.
All these things are actually reimbursable now what does and let’s say if you and I are collaborating on a patient and the patient is not involved.

[20:41] Hey Randy got this patient here when I work with you on and our conversation is billable on your side of my side my note to you that I present to you is actually billable by itself as well.
So all these are actually brand new and the idea of Integrative Health is just more communication more communication with the other caregivers of the patient.
And also our conversation with the patients families even if the patient’s not there is also have new billable CPT codes there as well.
And so we are starting to see that there is already a structure engineering structure of communication within the United States,
that we are that is already there not only do we need to take advantage of it we have to do the patient a due diligence to investigate that,
and then incorporated into what we think how medicine should be practiced which is something that I think has been.

[21:34] Missing and you know.
Is it was my generation that was there when the electronic medical record.
First appeared in I will tell you quite frankly I thought it was going to be the greatest thing that ever came along but when the final product became available became available it simply was not I because it was too difficult too,
operate and you knew that you know you could get a level five examination by claiming that you did all the things you know the family history the medication history and all those kind of things but you didn’t necessarily have to,
a lot of information in there and and what I hear you saying and I hope this is what I’ve heard is that there is actually.

[22:18] Reason to believe that the technology has actually Advanced to the point where you will be rewarded.
For taking the time to make those things happen is this true.
It is true let’s take an example of what you said right here right is the EMR the greatest thing that ever.
That ever was developed the answer is yes just not for doctors it’s
it’s not just that but you know data is worth more than than patients lives unfortunately when it comes to corporations institutions right
whoever holds the data holds the key and then and then companies can decide whatever they want to use with that particular data EMR,
shifted the power from the Physicians to the to two other other corporations.
Drastically because it used to be that the Physicians held the data
now the EMR holds the actual data and because things are on cloud and stuff like that we they can go in and look at all sorts of different population the population data so it’s a lot of power to kind of play with right.

[23:30] You know is it is it detrimental for like the physician-patient relationship yeah yeah it’s because a lot of doctors including myself from our earlier days I had to type that can’t look my patient eyes as or telling me stuff.
And and there’s no way they can capture all of that information after the the visits over at the end of the day you know especially like my wife is OBGYN,
you know there’s there’s a lot of information to really capture their and it’s really hard to do so in just a few minutes right.

[24:00] And then came this whole thing on templates all templates are great well templates were designed to capture enough information to bill out a specific code.
And and so now you have all these companies that have preset template so this is your anonymity 14 template this is you’re not into 13 template is you’re not into and 510.
And so which by the way also went out the window and 20 21 because the criteria is completely different now.
So so all these templates came from from the practice medicine in terms of like the business of Medicine
but it’s still created a lot of detriment to the conversation between the The Physician and the patient
so who suffers the patients suffer the doctor suffer the administrative stuff for the medical assistants suffer because they can’t
because all your all your notes look the same right can’t tell what’s doing what and so all the systems suffer.
Pretty drastically and then not only that you’re not really capturing valuable data you know.

[25:06] To create that change we have to not work against the system but work with what’s already been developed you know.

[25:16] You know last year on the physicists practice automation Summit that I interviewed you on interview Haley Fisher right who was the CEO of MDMA.
Who was responsible for getting these CPT codes approved for telecommunication but the anybody know about it and no not really
you know you know and I still to this day I was time to ophthalmologist our ophthalmologist this morning and I’m like hey did you know and he,
here he’s the lead ophthalmologist as a hundred Ophthalmology Group of huge groups like did you know,
divided we actually chat about a patient for five minutes and you have to give me a console know you can actually bill for it that just blew his mind right I was like I did you know that if someone has abnormal exam you call them because of the abnormal exam.
Right did you know that your doctors can actually build for that blew his mind even more and then from a hundred Ophthalmology practice you know that translates into seven figures of lost Revenue,
that they didn’t know that can they can capture of things that already went into playback in 2017 and it’s 2022 right so.
So this is what we have to get kind of hyper focused on is engineering medicine the way that we want to practice as doctors giving Pap back the power to the doctors,
but understanding how the system actually works.

[26:35] And creating change from that level instead of trying to you know fight everything because it kind of hurts me to see a lot of doctors exit the insurance system
because a lot of people on Medicaid Medicare do need that same high level services,
and so it’s it’s you know I understand why people leave the insurance system but there’s also another way and so integrated practice Builder
you can’t tell is all about how do you integrate your values into the insurance based system and practicing medicine
hi I’m Rhonda Crow founder and CEO Forum D coaches
here on RX for Success we interview a lot of great medical professionals on how they grew their careers how they overcame challenges,
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And now let’s get back to today’s interview.

[29:22] To to expand the discussion just a little bit more I want to ask you do you think this intrusion of the of the electronic medical record as we now know it into a.
Previously fairly intimate communication between doctor and patient that got lost I think.
Is that what is that what made us burned out no I think that’s part of it right let’s talk about burn out for a second,
burnout is basically having much higher expectations and not fulfilling them over a long period of time that’s sort of my definition of burnout it’s also the same definition for depression,
since so it’s yeah it’s Expectations – reality in the way that we perceive reality.

[30:17] So let’s talk about what the promise was what the deliverables were when it comes to medical education the deliverables were,
that you become a doctor or nurse practitioner or PA whichever one you are in the healthcare field you’d become the sort of provider and then you exist to serve the patients and that gives you fulfillment.
Right so that’s the promise you know you see that on TV and media and social media and stuff like that right.
The reality and if you know the pandemic didn’t accelerate that Hunter fold I don’t know what else would have.

[30:55] Is that most people are getting their value in health not from doctors you know an 18 year old Tick Tock influenster has way,
more clout than doctors do at this point you know it’s a very different day and age and so you know I’ll give you example is we had a there’s a 21 year old that was on YouTube talking about her journey.
With with with with crohn’s disease and and all sorts of very like misleading information,
because just because a pertains to her doesn’t necessarily mean it pertains to like everyone right and and so in some like wow you know the information is there
and as integrative practice Specialists and being trained in like integrative and functional medicine,
you know the the influencers are the people to really compete with with a lot of information now I don’t call it misinformation I just call it information,
because I actually don’t believe there’s any such thing as a Miss information because information is how we perceive it,
no this girl she’s 21 she’s doing great because she’s sharing her story with the world which is which is a lot to applaud.

[32:08] But if people take it as a universal advice then that’s not going to be the greatest thing and the reason I mention that is because this morning I opened up my secure message,
and lo and behold one of my patients quoted this this this girl,
and actually send me the link what do you think about this should I do x y and z,
and so so the promise the deliverables of medicine is that you’ll be the one taking care of the patient but when it comes down to it,
you’re also battling against other things that are out there right and so.
And so while the EMR has a big contribution I think the way that we receive information now has a much larger contribution but here’s the cool part Randy here’s the cool part.

[32:58] There’s ways of addressing this that can create an even higher amount of value for the patients as long as the communication,
is there right and and we’re not taught to communicate in med school residency were really not,
well let’s talk about we’re integrated practice Builder fits into all this who needs it
and where do they find it a while ago I decided to take the word need out of my vocabulary and replace of the want so who would want something like this so it’s a Doctor Who’s really had enough.
Who understands that there’s more to Medicine than quitting it there’s more to take an insurance than quitting that.

[33:43] And it’s the people who are really looking for a transition of some sort and not necessarily a career but transition of a mindset.

[33:52] So there’s different sections on the anchor to practice Builder.
My favorite one is called a psychology of business you know a cola MBA ish so.
Yeah it’s about like how do you how do you have how do you reverse a lot of what’s taught to us and that’s cool and think like a like.
The business person but the deliverable is created an enormous amount of value for the patients.

[34:17] How do you like 10 x 2 value for you have for your patience and and then create a business out of it.
And so there’s a lot of marketing in there as well because I used to own a marketing company that says my background.

[34:30] And then and then another one is on Special Operations from the team leadership standpoint how do you how do you develop the best company culture how do you create videos within your organization so you’re not burnt out all the time.
How do you not be the smartest person in the room during your morning morning Huddle’s,
and so and then and I have some things that are a little more specific or a lot more specific like how to integrate the new taxonomy of health coaches into your practice.
How do you do one on many visits or we call group visits with sure medical visits and building that’s associated with it.
And so it’s really the the ends end of what I wish I knew what I really learned from Texas Center for lifestyle medicine and developing this practice here.
And all the struggles I really had of what that really look like and it’s really a shortcut into sort of a mentality.
Of what I think Health should.
Really be like if the Physicians were in control so that’s what that is boy that sounds like Shangri-La right there the physicians in control,
so if somebody is interested in they want to get involved in this how do they access the integrative practice Builder and what are the what are they likely to experience.
Yes so you know I asked him in a straight is to share the link with this with this podcast.

[35:52] Yeah so go ahead and click on it and in the show notes and that’ll take you to a page where it’s all me
you’ll see me in my raw form and then you can access it in a right away these are pre-recorded videos and it’s really long and it’s CME by the way as well
so so go,
yeah it’s big plus so a lot of you Physicians who are employed who have allocations for CME funds can actually utilize it on here and so
it’s it’s instant access and what I want people to get out of it is the fact that.

[36:29] There’s just so much more to Medicine than to life,
and finding the joy in medicine requires a big change in mentality and that’s the primary focus of,
of integrated practice Builder so yes it’s business but more importantly it’s it’s it’s reducing burnout we’re actually letting go of burnouts.
And its leadership as developing the most meaningful relationships that you can imagine in fact the very first video that you guys see is me and my.
My seven-year-old daughter talking,
and and and that’s that’s the type of atmosphere that we want people to have I love the tagline it turns.
I’m probably not quoting you precisely but as I scribbled in my nodes you say the integrative practice Builder turns docks into Integrative Medicine rock stars.

[37:26] That’s pretty that’s pretty exciting that’s right.
Yeah rock stars yeah and I like to use those words because you know.
But we have to do is we have to play you know there’s a great book called essentialism and I think it’s.
No chapter 7 I think that talks about one of the most essential things that we have in our life other than like having food Water Shelter is actually play.

[37:55] And if we can create that play as essential as part of our Lives which were trained not to do as Physicians.
Then we can be rock stars that’s how I came up with that so true very wise well.

[38:12] Dr. Chang won the founder of Texas Center for lifestyle medicine and now the founder of Integrative practice Builder
as usual it’s been a fascinating conversation and I really do appreciate you taking the time to be with us today.
And to our audience I hope you will take the opportunity to check out the integrative practice builder website and
learn more and we’ve got more information for you in our show notes of course and if you haven’t heard my prior conversation episode number 72 with dr. Chang gwon,
I think it’s a pretty good little chit chat and I would recommend that to you as well.
So Chang thanks again for being with us it’s been a pleasure as always.

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[39:50] Music.