Thank you for tuning into the Becker's
Healthcare Podcast. I'm Ali Gamble, vice President Editorial, and today I'm
catching up with Dr. Maria Ansari. Dr. Ansari holds numerous positions. She is c e o and Executive Director
of Permanente Medical Group, president and c e o of Mid-Atlantic
Permanente Medical Group. Together, these two medical groups have more
than 11,000 physicians and 44,000 staff delivering healthcare to more than 5.4
million Kaiser Permanente members in Maryland, Virginia, Washington
DC and Northern California. Dr. Ansari is also co c e o of
the Permanente Federation, the National Leadership and Consulting
Organization for the eight Permanente Medical Groups. Dr. Ansari, thank
you so much for joining me today. Wh where do we find you? I'm in, uh, Oakland, California.
That's our headquarters. And, um, and second week on the job. How have things been going so far? It's been fun. Um, you
know, I've been, uh, with the medical group for
nearly 20 years, and so I, um, I've been in transition for this role for
about five months and I'm ready to get started. Were you always based
in Oakland or is that, did the change in role
also bring a move for you? It's a move. Uh, I, I started my career in 2004 at the
Kaiser Permanente San Francisco facility, and I've been there
up until about a month ago. Okay. Well, especially
in such a busy time, we are really grateful to get some time
with you, Dr. Ansari, and we have a, a big topic we're gonna
be digging into today, and that is the physician
shortage. This is something that, as I've shared with you at, you see throughout the press
discussed at a high level, you bring such a valuable and unique
perspective to this topic. I'm, I'm really excited to dive deeper
with you. Um, you know, let's start, since you're a problem
solver, w what steps, if any, are the Permanente medical groups taking
to address the physician shortage right now? Are there any innovative strategies that
you're putting to use to better attract and retain physicians? Yeah, I'm happy to talk about it and
I'm glad you're bringing it up, Molly, because I think it's, uh,
under discussed topic, we're expecting at least a
hundred thousand physicians
short in the next decade, and that's going to primarily hit
primary care. I mean, we knew it before, but the pandemic really exposed how
valuable and important essential primary care is to the
health of a community. And when you don't have
adequate primary care, you have increased morbidity
and shortened lifespan. So primary care is essential,
the physician shortage, what we're trying to do to address
that is really start and pipeline development with high
school and college students. So one thing we know for sure is that
the greatest shortage is in the rural areas, and when you recruit from a
rural area, you're more likely to have, uh, students return to their, to where they grew up to practice. And so one of our strategies
is to recruit and retain from, um, in Northern California from
our Central Valley location. And so we have a innovative program
that we've done a joint venture with uc Davis in Kaiser Permanente, where we do a summer program with
college freshmen and, and sophomore, uh, freshmen and sophomores
from the Central Valley. And these are primarily Spanish speaking
students. Uh, and they, we expose them, uh, to pharmacy research and other health
fields to try to get them to come in to medical school. Um, we have
other medical scholars programs, uh, with, um, community high
schools and a college, uh, the Napa Valley College called
the Medical Scholars Program. We're just exposing people to healthcare, having them have mentors and
really try to bring them in early. I think another big problem
is the fact that primary care is not well remunerated compared
to some of the specialties. And so we're just seeing that people are
coming out of medical school with huge debt. And one of the things that we did was
start our own medical school in southern California. That school is currently
tuition free and we are specifically recruiting for
underrepresented minorities and, um, people who are interested in primary
care. And that's become very competitive. That school has 11,000
applications for 50 spots. So we need to continue innovative
programs like that throughout this country and so that students are not coming out
with $400,000 worth of debt and trying to get them, um, launched into a career where
they can come out debt free. So loan forgiveness is another
big thing that I'm advocating for. You mentioned so many
important things there. So many important contributing factors
to the physician shortage. Also, strategies to solve for, I I, I really appreciate the note about
the remuneration for primary care. Some specialties are able to better make
up for that debt incurred in medical school at a relatively quicker timeframe
than specialties like pediatrics, primary care, family medicine. Mm-hmm.
. Um, you, you know, I, I wanted to also touch
base with you too about, I, I love the idea of students
graduating and returning to their home town to practice. Mm-hmm.
. Are, are there any other ways
that the healthcare system, whether it's medical schools
or health systems, can better represent what it's like to
practice in a rural setting? It, it seems like a lot of academic medicine, it's almost biased toward practicing
in major AMCs mm-hmm. , major tertiary medical centers. Do you think there's any adjustments
that need to be made for really helping students understand the
variety of settings that they
could bring their talents? I, I think for sure, yes. I
think when you're in training, if all of your rotations, because we have students who go through
medical school and then they do their clinical rotations in
the university hospital, and that is a really skewed
way of looking at the world. Everything looks like a zebra and you
don't actually see the bread and butter of medicine. And so really promoting
community-based organizations to community-based hospitals
to work with. So when, um, if the core part of the rotation is with
an affiliated hospital that's not with the university, and we're,
you can actually have, uh, physicians help teach those students,
it actually brings a greater, I think, recruitment, uh, for those community-based hospitals as
well if they know they get to work with students. So it's a win-win both ways. Well, Dr. I, sorry. It's great to see how much effort and
energy and problem solving Permanente medical groups are
putting into this problem. But what about at the
national or system level? What do you see that needs to be done? What areas of improvement are still in
need of attention or greater problem solving and creativity?
With the physician shortage. I talked a lot about primary
care, uh, shortage and, and I think it's physician
shortage all around. But I do believe that developing
loan forgiveness programs for underserved areas like rural
areas for all physicians, and then particularly for primary care, I think we need to invest and expand our
residency training programs and link it to areas where there are known shortages. And we've been advocating for that. I just was in Washington in March
with all the other CEOs of the Permanente Medical Group
trying to advocate for loan
forgiveness and expansion of the residency training
programs. There are, um, I also believe that we should be
supporting streamlining foreign medical graduate job opportunities in this
country. That's how my father came, uh, to this country was when there was
a physician shortage in the 1960s. And finally, I think in order to
improve the health of our communities, we need to invest in, uh,
advanced practice providers
and pipeline development. There. We have our own school of allied health
sciences at Kaiser Permanente, uh, to train healthcare workers, but nationally we need to expand
physician's assistants and nurse practitioners as well as they
can really serve, um, um, and help extend our reach. I'm so glad you brought that up, cuz as
a, a cardiologist yourself, you know, advanced practice providers, there's such a role for them and such
opportunity for them to alleviate the shortage. There's also a lot of
longstanding tension too mm-hmm. with where one
role ends and when other begins. Do you have any perspectives on that? If physicians were to ever come to you
with seeking your thoughts and how you think about that in, in the modern day health system as
we look to have expanded access, reduce health inequities, how do you see that relationship
between the physician and apps moving forward? I love working with our apps.
I, I don't feel that tension, although I've seen it and
heard of it. I think it's, um, we have to think about the way we
practice medicine as being part of a team and everyone practicing at the
top of their professional license. And there's a role for everyone. And
so if, if a nurse practitioner can, oftentimes they, and the
physician's assistants too, can focus on one area or provide,
um, broad scope primary care. But in my field, cause I'm a specialist, we often use nurse practitioners
to provide very specialized care, for example, in heart failure. And
they become so good at it, honestly, sometimes just as good as a
cardiologist for that focused area and really offload me to fo to focus
on really the most complex patients. And then our physician's
assistants, for instance, are helping us in the operating rooms
with cardiac surgery and helping us with post-op pacemakers. It's, it's
really a combined effort so that I can, I can do the things that I'm best at
and they can do the things that they're best at. There's no, there's a shortage of healthcare
workers and I think that there's some concern from some of my colleagues
across the country about just threatening their profession. And I think
there's space for all of us, uh, to work at the top of our scope. Patrick. Answer, you had mentioned from the top that
you feel the problem with the physician shortage is relatively under
discussed mm-hmm. , and I kind of wanted to explore
that thought one bit more. Mm-hmm. are, are there any drivers or factors of
the shortage that you feel are also under discussed or under-recognized? Are, are there any things that are making it
worse or exacerbating it that we need to pay more attention to? Yes. The reason I think it's
under discussed is because
I don't feel a sense of urgency from, um, from our legislators to even the
public about what's going on. And I hear people complain about
access to healthcare and they know it's important, but I don't see movement,
uh, to change the situation. And the, and it's been exacerbated by I think, the rising cost of medical school
education and the baby boomers retiring, so all the physicians who
are baby boomers are now retiring. We've done such a good job on prevention,
for example, on treating hypertension, on pr, on treating a heart attack so
that people are now living longer. It used to be, let's say 50 years
ago, if you had a heart attack, maybe you wouldn't survive it, but now you're surviving it and
perhaps you have heart failure. So now you're living with this
chronic condition of heart failure, needing more medical care. And
those people are hitting the, um, that the baby boomers are now in
that, that group that needs that care. And so it's, you're reducing
your supply as doctors retire, and you have a greater population
boom that needs that care with long, with more comorbid conditions. And it's a perfect storm and
it has to change because if we wanna improve the health of our
communities, we need to be able to address the entire wraparound services
that patients need. So yes, they're living with chronic conditions
and we're seeing a huge increase in mental health needs and
social, uh, we're having, we're starting to recognize more health
inequities and social determinants of health that need to be addressed, otherwise we really can't support
their total wellbeing. Right, right. And I wanted too, to understand if
what, what role you could see. Um, you mentioned the government
and I, and I agree with you, it's been interesting covering this. The forecasts were released so frequently
from the A A M C, for instance, and the physician shortage, what was
coming, um, what was looming overhead. Covid obviously worsened
that in those forecasts, but it's interesting how such a
widespread pressing an important problem is not met with, I would say the
urgency that you just described, um, by various stakeholders. You
mentioned the government. Do you see any other players
or stakeholders in healthcare, whether it be the private
sector, the health insurers, do you see any other opportunities for
them to help confront this problem along with providers? It's, it's a big one
for providers to solve for on their own. For sure. I don't think providers
alone can solve for this. Um, and yet I think that most residency
programs are sponsored by Medicare in Kaiser Permanente. We sponsor
our own residency programs. So that's one opportunity is for other
health systems to sponsor training programs. I think that thinking about, um, seed money for, uh,
medical schools, uh, really as a community benefit, uh, to support and donate and
sponsor students to go into, to go into medicine and
pay for their tuition, um, I think that's a big barrier
that's not recognized right now, particularly in the, I would
say in the last 20 years, people graduating from college can enter
a tech related field and immediately start earning money or enter a business
related field or any kind of technical field. And they're, they're
earning income. Now. When you go into medicine, you have four years of cumulate
debt and then a minimum of somewhere between three to eight years
of post-graduate training
where you're earning, you know, not much and you're not, your true earning potential is delayed
by 10 to 15 years and you're coming out with debt. So who's gonna go into that
field if there's no incentive, uh, to re um, um, uh, to support
them through that? It's a, you're taking up a huge upfront cost. And then healthcare, the other
thing that's not being said, and I, is that it's becoming
harder to be a doctor. Patient expectations are through the roof. Patients often self-diagnose themselves
on the internet and come in with a list of what they think they need. And, um, the demands are out of proportion to, um, what I think the healthcare system
can afford to provide right now. In terms of overall, um, care, when you look at the way that Americans
spend money on healthcare and what outcomes we've received from, from that
investment, it, there's a disparity. The country we spend the most
on healthcare, and we have, we don't have outcomes to show for
it in terms of maternal mortality, cardiovascular death rates, cancer. I'm very proud of what we're able
to collision. Kaiser Permanente, our cardiovascular rates
and mortality rates are 30% lower than the rest of the community. Cancer rates 20% less
health equity gaps closed. And I think it's because it's an
integrated value-based system that, uh, focuses on prevention. But most of the country is still
practicing in siloed fee for service, transactional medicine that
remunerates based on doing more tests and procedures that
don't necessarily improve
outcomes. We have to bring, bend that cost curve and really invest
in prevention, team-based care and, and population health so that we can
prove the standards of living for the entire community. Some really impressive
statistics. You just shared Dr. Ansara and you made mention that
KP sponsors its own residency programs mm-hmm.
, I'm curious, did that stem from there not being enough
Medicare funded residency programs or governmental sponsored residency programs? What were the origins of that
decision to stand up your own? Yes, we are the, for example,
in Northern California, we're 10,000 physicians at the largest
medical group in the country that's physician led and run. And even if we hired every single
graduating resident in the state of California, we wouldn't be able to
keep up with the needs of our, um, Northern California population. And
so really creating our own pipelines. I know when I first started
at Kaiser Permanente, I, within three years of starting, I pitched to build a cardiology
fellowship program because if you, it's the same thing I was just
saying, people weren't paying attention, but the data was out there. We
were expecting a shortfall by 2020. And so I pitched that. And right now, cardiology is not hard to recruit Northern
California Kaiser Permanente because we do have our own pipeline. And when people see that the
way that we can practice, it's such a great learning
institution. And we reward based on, um, aligned incentives with the
patients. So taking care, if you do the, if your patient never has a heart
attack and never has a stroke, that's the most desired
outcome for the patient. And that's the most desired
outcome for the system. And it's just a really rewarding
and ethical way to practice. And usually when our
physicians train here, they don't wanna practice anywhere else. And so it's been a really good investment.
And so I think pipeline development, um, and with, it does not
have to just come, uh, from Medicare supported funding. The other idea you mentioned that I wanted
to double click on, if you'll let me, is mm-hmm.
expectations, um, you know, people presenting with their own
internet-based research mm-hmm. Thinking that they have the same
diagnostic capabilities as specialists, for instance. And while I, I'm not an
advocate for paternalism in medicine, I also am very respectful
and deferential to expertise, um, to specialists and experts. People like physicians who go to school
and are trained to practice their profession. Have you noticed a difference as of
late with attitudes towards physicians? Are there any anecdotes or research, anything you can point to that can help
our listeners understand The internet's been around for a long time, but
something is changing here. What, what does that look like now? Yeah, I think it's interesting because I
actually really want our patients to have agency and their health. I want
them to get involved. No, I, I want every patient to have a continuous
glucose monitor if possible. You know, just, just for, even for a short term. I, I want them to know what
their blood pressure is. I want them to be engaged
and ask questions. And, but I also want our doc, our patients
to have trust in their doctors. And I think some of that
trust has been eroded. Look, I go onto YouTube too and
think I can fix everything. Um, but the truth is that I'm not a plumber
or I'm not a contractor. And when, even as a physician, because
I'm an adult physician, right? When my kids have
something, if I Google it, I'm scared outta my mind by the time
I'm done with my internet search, I think they need, you know,
a transplant or something. And I think you just have to really, um, recognize that physicians have experience.
We deal with this stuff all the time. And so what you read a snippet or even
if you do quote unquote your own research on Google, you don't have the practical
expertise and the context of what the denominator looks like and what the
natural history will be like and how it presents, um, in real life versus what
it looks like on a screen or in paper. So I think, um, it's eroded trust
for sure, I think with patients. And what I try to do is when a
patient comes in with, to me and says, you know, I'm here because I need a cardiac
catheterization and this is what I've diagnosed myself as, I usually try to just take a step back
and realize that that person's really anxious and, and that
person is feeling defensive. Like they need to advocate for
themselves cuz they think I won't. And I think what I try to do
is just say to them, listen, I know you're having chest pain
and I wanna hear all about it, and we're not gonna leave this meeting
or this visit until we get to the bottom of it. And I'm here to help you. And if it takes that we need to do the
procedures that you think you need, then we're gonna do it. But I'm here with you and I'm gonna
listen to you and listen to your story and we're gonna figure it out together. I think that kind of like kind of
settles the room down a little bit. And I think patients have felt so, um, I know it's coming from a place
where patients haven't felt heard. And I think that's part of where we can
work as doctors to make them feel heard and understood so that
we know that we're, um, arriving at the best outcome together. Um, but it is sometimes puts us in an
adversarial position and post pandemic, I would just add that we're in
this, um, Uber Eats culture where, or you order something on Amazon and
they offer to deliver it the same day within a two hour window. And
that's the kind of culture.