Introduction

Now, I’m being pretty careful here because med schools are super sensitive about their curriculums. And I am sensitive to the fact there’s much to teach in four years. So, throwing no shade here, what do I know from the Krebs cycle? Choices of what to teach are tough. With that disclaimer, in this healthcare podcast I am speaking with Adam Brown MD, MBA, about an article he wrote entitled “Dear Medical Schools, Educate Students on the Business of Medicine—Without it, you are doing your students a disservice.”

Let me give you Dr. Brown’s list for the “why teach the business of medicine.” He says:

1. The role of physicians in medicine has changed, and we dig into this in the episode.

2. There’s an expectation mismatch. Docs are investing 10 years and, on average, $200K to $300K in real dollars to get that MD or DO. You don’t want those new physicians quitting on the quick because the reality is so different from what they thought it would be. Not being up front about the business of medicine is like hiding the reality of the situation instead of preparing them.

3. If you don’t understand the business of medicine, you do not know how to advocate for yourself or the profession or even patients in a way that is compelling to the current set of decision-makers.

As maybe a corroboration here, may I just report that I probably have gotten (conservatively) 100, 150 emails and LinkedIn notes from physicians who say basically some version of the same thing: Thanks so much for Relentless Health Value. I wish I would have learned even the basics of what you cover in med school. If I had, I would have been able to help myself and help myself help patients far better.

4. Docs are the ones with the prescription pads. Docs are just functionally the gang who are driving costs that patients and employers and taxpayers ultimately incur. Not knowing the how much or just the whole story here can inadvertently contribute to clinical morbidity, because patients who fear they cannot afford care do not follow doctors’ orders. We should get real about that. Or if they do follow doctors’ orders and go into debt … I mean, there’s just study after study in oncology and otherwise that shows patients who cannot afford their care have worse outcomes. We cannot hide from this any longer.

5. The last reason is that there’s lots of things that docs can do besides just be at the bedside. Not giving insight into these alternative paths seems unfortunate for any doc who maybe wants to mix it up some because they’re feeling burned out or in a different season of their life looking for something more aligned with where they are as a person.

So, now let’s think about this whole question from the standpoint of the system itself—from the standpoint of doing better by patients. Why is it important to teach docs the business of medicine? Let’s start here.

When physicians do not understand the business of medicine, it’s harder for docs to get into boardrooms and have their voices heard. Not teaching the business of medicine in med school might be one reason why there is such a shockingly small percentage of doctors on the boards of directors at major nonprofit hospitals (listen to the show with Suhas Gondi, MD, MBA [EP404]) and why there’s so little “dyad leadership” in the ranks of both clinical and payer organizations, etc. And even fewer nurses are in organizational decision-making roles, by the way, despite nurses actually being the most trusted profession—even more trusted than doctors by 14 percentage points, according to Gallup.

One way to interpret this lack of docs and other clinicians in the boardroom is simple cause and effect. Doctors are losing control and ownership—and I mean this in literal terms—of the organizations that run the business of medicine, which controls the medicine of medicine.

Chad Erickson wrote a comment about this on LinkedIn that I thought was great. He wrote, “Opportunities for physicians to really control or even impact the 86% of healthcare outside of their practice are being reduced every year. We expect doctors to make the decisions and be accountable for patients and outcomes, yet we are taking away their ability to do so.”

And going one level deeper here on how not having enough docs in admin roles becomes a snowball rolling downhill kind of downward spiral, I’m gonna quote Jeremy Granger, MD, FAAP. He wrote, “When you are a physician administrator, it can be very strange. There is tremendous pressure from administrators to think and act like one of them and give insight into how to best coerce physician behavior to align with administrator-determined goals without necessarily involving the physician with setting those goals. When you advocate instead with your physician hat, you can find yourself ostracized from that administrator clique. You realize that they view physicians as knaves and you as the Judas goat. You either pick a side or, if you’re lucky, you land with a team that has physician leaders equipped with equal power as administrators.”

So, you see what happens. Doc gets an admin role and either chucks their stethoscope and their patient-first mindset out the window to fit in, or they quit. And then we never get to any sort of critical mass of clinicians in leadership roles that would reset the organizational ethos.

So, here we are. Too few mission-driven and business-savvy docs in boardrooms mean patients get the kind of care they’re currently getting and at the prices we’re all currently paying. From the standpoint of doing better by patients, I hear story after story about some doc who was under the impression that, I don’t know, working with a private equity firm to do a roll-up of all the specialty practices in a local market was pretty cool and a totally victimless strategy. Or the surprisingly high number of docs prescribing drugs on that most wasteful spending list. There’s one on that list, for example, that costs taxpayers or an employer $2000 when that drug consists of basically two $15 over-the-counter meds mashed together—and yet there’s the impression that the $2000 drug is a better financial choice because there’s a co-pay card and the patient out of pocket might conceivably be less … until it isn’t, of course, because it’s not like that additional $1970 in cost suddenly becomes free.

Or what happens when a clinician is told to order largely unnecessary MRIs because workers’ comp covers everything and no one cares—so this kind of thing continues to just happen … all this stuff. It takes a broader understanding to get the why and create the intrinsic motivation and necessary insight and right language and arguments to make things better.

But all of this is about patients. If I’m talking to margin-driven people sitting around the conference room table with their calculators, are there any organizational consequences, meaning financial consequences, to not making sure doctors understand business and have a seat at the table? Here’s two (there’s probably more):

1. Staff turnover. If that’s a concern for any organization now, and if moral injury is cited as a reason for that turnover (which it often is), moral injury doesn’t happen when organizational demands are aligned with clinician values.

2. Successful value-based care isn’t gonna happen if docs don’t understand the business of medicine. Listen to the show with Eric Gallagher (EP405) or the one with Amy Scanlan, MD (EP402) or Larry Bauer (EP409). There’s like 10 guests who essentially say the same thing. Docs who are in the dark about how the world actually works IRL cannot be an aligned force helping move past the FFS (fee-for-service) status quo and the whole business model that underpins that.

Adam Brown, MD, MBA, my guest today, is a practicing emergency physician, board-certified ER doc. He recently founded ABIG Health, working with healthcare companies on communication strategies and advising investment firms. He’s also a professor of practice at the University of North Carolina, Chapel Hill.

Mentioned in this episode is a Tweet by Brendan Keeler. Also, Dr. Denver Sallee’s very inspirational predictive scheduling work.

I’ll leave the last word on this to Michael R. O’Brien, MD: “You don’t overcome the corrupting influence of money in medicine by ignoring its existence. … To slay the dollar-eyed dragon, we must be able to see like the dollar-eyed dragon.”

You can learn more at ABIG Health and by reading Dr. Brown’s bimonthly column.

Adam Brown, MD, MBA, is a board-certified emergency physician, entrepreneur, and accomplished healthcare executive whose professional journey traverses clinical practice to strategic leadership.

Having risen through the ranks at Envision Healthcare, Dr. Brown’s tenure there culminated in his role as president of emergency medicine, where he spearheaded the COVID-19 response and clinical communications. His impactful leadership led to his appointment as chief impact officer in 2021.

In 2022, Dr. Brown left Envision and established ABIG Health, a healthcare strategic advisory firm. Additionally, he took on the mantle of professor at the University of North Carolina, Chapel Hill, Kenan-Flagler School of Business (his alma mater), teaching healthcare operations and strategy to MBA students. He is the advisory board co-chair at the Center for the Business of Health and on the business school Board of Advisors.

A frequent media presence, Dr. Brown has been featured on CBS, Yahoo Finance, BBC, and local Washington, DC, outlets, speaking on various healthcare issues. His column, “Prescriptions for a Broken System” in MedPage Today, showcases his commitment to meaningful change in healthcare.

His passion for empowering informed health decisions shines through his roles as a communicator, leader, and strategist. A recognized thought leader, his ability to connect, envision, and lead underscores his impact on shaping healthcare.

08:49 What does it mean to teach the business of medicine?

11:04 The four Ps that are key within the business of medicine.

13:27 Why is it important for doctors to understand the business of medicine?

21:46 “Things don’t happen without a physician’s signature.”

27:27 Why physicians who understand the business side of medicine can broaden the view of outcomes for the business decision-makers.

28:30 Why is it important to make sure physicians are in the boardroom?

29:36 EP404 with Suhas Gondi, MD, MBA.

30:52 “We are getting what we designed.”

33:37 Dr. Brown’s advice for clinicians in the boardroom.

38:21 The work of Denver Sallee, MD, MMM, using artificial intelligence to do predictive scheduling.

You can learn more at ABIG Health and by reading Dr. Brown’s bimonthly column.

@ERDocBrown discusses teaching the business of #medicine on our #healthcarepodcast. #podcast #digitalhealth #valuebasedcare #healthcare

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