Taking Healthcare by Storm: Industry Insights with Dr. Peter Kowey

In this episode of Taking Healthcare by Storm, Quality Insights Medical Director Dr. Jean Storm speaks with Peter Kowey, MD, Professor of Medicine and Clinical Pharmacology at Thomas Jefferson University, Emeritus Chief of the Division of Cardiovascular Diseases at the Lankenau Heart Institute, and the William Wikoff
Smith Chair in Cardiovascular Research at the Lankenau Institute for Medical Research.

Dr. Kowey discusses his book Failure to Treat, using patient-inspired stories to show how modern healthcare has grown less human and more complicated. He highlights harms from electronic medical records, profit-driven screening, malpractice-driven defensive medicine, administrative control, drug advertising, and burnout, and calls for universal access to basic care.

If you have any topics or guests you'd like to see on future episodes, reach out to us on our website.

The views and opinions expressed by the host and guests are their own and do not necessarily reflect the views, positions, or policies of Quality Insights. Publication number QI-061226-GK

Transcript

Welcome to "Taking Healthcare by Storm: Industry Insights," the podcast that delves into the captivating intersection of innovation, science, compassion, and care. 

In each episode, Quality Insights’ Medical Director Dr. Jean Storm will have the privilege of engaging with leading experts across diverse fields, including dieticians, pharmacists, and brave patients navigating their own healthcare journeys. 

Our mission is to bring you the best healthcare insights, drawing from the expertise of professionals across West Virginia, Pennsylvania and the nation.

Subscribe now, and together, we can take healthcare by storm.

Hi, everyone. Welcome to another episode of Taking Healthcare by Storm. I am Dr. Jean Storm, the medical director here at Quality Insights, and we're doing things a little bit differently today. My guest is Dr. Peter Kowey, a renowned cardiologist and cardiac electrophysiologist who has spent his career caring for patients with heart rhythm disorders, conducting research, teaching the next Jeanration of physicians, and contributing to the evolution of cardiovascular medicine. So if we're talking about heart rhythm disorders, is a big problem, obviously. But beyond his clinical work, Dr. Kowey has also become a powerful storyteller. His latest book, Failure to Treat, uses real-world inspired patient stories to examine some of the most pressing challenges facing healthcare today, from electronic medical records and medical malpractice to pharmaceutical advertising, administrative control, and physician burnout. And as someone who uses clinical scenarios, case studies in a lot of my education, I know how powerful this form of communication can be. These stories are really inspiring, and they really make you think. Through these stories, Dr. Kowey asks an important question: How did a profession built on compassion and trust become so complicated? I think about this a lot As I have been a nursing home physician for a long time, and I wonder this often, that we had a profession built on compassion and trust, and it's become very complicated. And he's also answering the question: How can we fix it? Dr. Kowey, thank you very much, and welcome to the podcast. Jean, first of all, I wanna thank you very much for the invitation, but also for being willing to take on some pretty tough topics in healthcare through your career and on this podcast as well. I am an admirer. Oh, thank you. Thank you. Yes, my, tough topics is my middle name, I think. So I just wanna you know, set the stage here. You spent more than five decades in medicine, and you write about growing up in a family where no one had gone to college. So what first inspired you to pursue becoming a physician, and how did that background shape the way you approach your career and your patients? I think this plays directly into what you were just talking about a few minutes ago, which is a profession that was built on compassion and caring. And so when I was a little guy our family doctor was an icon. He was a deity. He worked by himself in his office. He didn't have any nurses or secretaries or anything. He wore really nice suits. He was a real gentleman, and my parents worshiped this guy because they would go to the office... There were no appointments. You went to the office and waited your turn to see him, and then he would call you into the office, and he would, examine you. In my case I remember getting vaccinations and shots and stuff that the usual kid stuff. And that's my dog in the background, by the way. He's barking at the FedEx man. Oh, we love dogs on the podcast. He's our little watchdog. But anyway I admired this guy tremendously and so- And I like science. I mean, I liked, I liked biology. And when people would ask me what I wanted to be when I grew up, I would say a doctor. I had absolutely no idea what I was talking about. I had no concept, but it sounded like a good idea. And my parents, who n- neither of whom got out of high school, were very education-oriented. And so when I said that, they latched onto it and reinforced the idea for me. And, so for all my entire life, that's really the only thing that I thought that I would become and I eventually did obviously do it. But it... I'm a lucky person because I did well without really knowing what I was getting into. I went to the right... I went to a very good college, I went to a very good medical school, and I was trained in really good places and um, I consider myself, myself very fortunate to have found my way into this profession. But I did it precisely for why you said, because I was so enamored of the idea of being able to care for people. M- this guy, by the way did home visits and I remember when he came to our door to see one of us, like my mother when she was ill it w- it was, honest to God, it was like Christ coming off the cross. I mean, it was, such an impressive event because when he came, he... all he did was care for her and talk to her and hold her hand. And I'm sure, I'm not even sure any of the treatments he gave her made her any better but she got better and she felt really confident because he was such a good doctor Yeah. And I'll say my father is a semi-retired physician, internal medicine physician. And I say semi-retired because he still works in the free clinic and he's in his mid-80s. And I miss that time that you're talking about you know, where these physicians were Christ-like. And I'm not saying physicians should be Christ-like, but it just was just very... It just different, right? Very different. There was a, there, there was a, an ambiance. There was a, there was something about them. And they were really authentically interested in caring for people. B- back then, there just wasn't a whole lot of money in medicine. You know? The- people couldn't make a lot of money. It wasn't money that motivated them. They really did care about their patients. And they were able to, to do-- They were able to take care of patients the way they wanted to. Yeah. So I wanted to jump in and start talking about these stories which I feel like are so profound. And story one is called The Electronic Medical Record: Boon or Bane? And this is Mrs. Francis. And I know how I feel about the electronic medical record, but I think we'll talk more. And in this story, Mrs. Francis, you explore the impact of the electronic medical record, EMRs. EMRs are supposed to improve care and coordination, but they've changed the doctor-patient interaction. And in my nursing home, I saw patients primarily in the nursing home, but also in the hospital, and I just did not bring the computer in. I d- I don't do that. I don't make a practice of doing that. But I, did a lot of charting in my car and at home after hours when I was in direct clinical care. So what does this story reveal about how technology can interfere with the human connection in medicine? the, electronic medical record was invented, most people don't realize this was really not invented to facilitate patient care. It was invented to document and to bill. It w- it, it was a financial tool so that hospital systems would have a, hard record of physician-patient interactions, and that they could facilitate their billing process and then obviously document a lot of stuff. That's why it was invented. And what it did is it made physicians do a lot of work that they ordinarily would not have had to do to keep up with this record-keeping thing. And you hit something right on the head there, which is unfortunately what patients experience is that when they walk, when the doctor walks into the room, the very first thing that many of them do, unfortunately, is go to the computer. And when they were designed our latest set of examination rooms, the way they put the computer on the wall is we would have had our back to the patient while we were looking at the computer. We, fixed that but that's h- that's the level of insanity, where we're not even looking at the patient, let alone listening to the patient, and concentrating a lot more on what's happening with the keyboard. the story relates several of the ills of the EMR, and one of them, if in this particular patient's example, is that it, it is a poorly kept record of what's really happening with the patient. So in her case she came into the hospital and told a nurse that she had an aneurysm, and the nurse assumed it was an abdominal aneurysm, when in reality... These are, by the way, all true stories, anonymized, but true. The nurse thought she m- it was an abdominal, but it was a thoracic aneurysm, and so they did the wrong tests. She left the hospital never properly diagnosed a- or why she was having chest pain. What was really happening is she was dissecting the aneurysm, and she died the next day. But the problem was that nurse's note was cut and pasted into everybody's note during the patient's hospitalization so that the truth really never emerged in this morass of, verbiage that's that is the record. So it's, evil for lots of reasons. In the case that in this case example, it was evil because of poor record keeping and the way that people sometimes try to do shortcuts. Yeah. copy and paste. Yeah. Exactly. Yes. And I don't think most patients know about that, so we could probably talk about that for a long time. But you have so many more stories that I, I kinda wanna talk about. And the next one is about healthcare screening, which people think What could go wrong?" you know, "I should have screening for everything." Like, you hear about people who are, like, getting, wanting full body MRIs just for whatever. So this story is Healthcare Screening for Fun and Profit about Mr. J. And y- in the story, you highlight how screening tests, often promoted as life-saving, can be driven more by profit than by patient benefit. And I'm just gonna say, I think that this is a sticky subject, because we have to be very careful, around people are very black and white, all or nothing in their thinking anymore. So in, in this story, what what are you trying to illustrate about the unintended consequences of over-screening? So I, first of all, I agree with you that you can't throw out the baby with the bathwater here. There, there is an advantage for testing in specific clinical circumstances that... and sometimes that does include sort of a screening process. But if it's in the story, as you recall it's, an unsupervised visit to a facility where they were doing vascular testing. So they told you We'll do a whole bunch of tests to find out if you have disease in your carotid arteries or your heart or whatever." And because the person in the story didn't really have a learned intermediary, he got stuck with a test result that he didn't really know what to do with, and unfortunately fell into the hands of somebody who wanted to do a procedure and harmed him with the procedure. So the plea here isn't not, is not to avoid all screening testing but to be circumspect and to understand why you're doing it and what to do with the results. There, there was a, just to give you an example, Jean, there w- recently I w- I was watching television, and there's a company now in Philadelphia that is doing brain imaging, and they're looking for brain tumors in an unscreened patient population. A- and as you know, the majority of brain tumors are benign. But if you get one of these tests and they find a tumor you're off and running, right? How do you know whether it's malignant or benign? And what are you gonna do about it? How are you going to find out? And they don't talk about that. It's a $2,000 charge, by the way, out of pocket for this test. But what do you do with the results? What do you do with a positive result? How do you deal with it? Brain biopsies obviously are not easy. The plea in the book is, to make sure that you understand why you're getting the screening and what are you gonna do with the results when you get them, how likely is it that the result is going to be a true positive versus a false positive. Yeah, and I, I think it's very interesting because I've provided a lot of education to patients and families around that. People just say, " I just wanna know. I just wanna know." And I don't think they understand the consequences of knowing. Sometimes it's better to not No, it's a, no it's a scary business. and now with Jeantic testing, it gets even more complicated, right? I mean, now you can find out if you're going to get... There was a story in the, Philadelphia Inquirer yesterday about a woman who found out from Jeantic testing that she's highly susceptible to developing ALS, Lou Gehrig's disease. And she's only in her 20s or 30s. She has a, greater than 85 or 90% chance of developing the disease. That's a pretty big load to drop on somebody at that age and what does she have to look forward to? It's I'm not saying it's not a good idea, I just think we need to understand the repercussions. I agree. So shifting a little bit to medical malpractice. And so I practiced in West Virginia for about 10 years in, in the nursing home environment you know, a litigious place in a pl- re- in a litigious healthcare environment. So this story, The Medical Malpractice Disaster, Mrs. Apple, it examines the ripple effects of the malpractice environment, and I think a lot about defensive medicine and how that is negatively impacting everyone, patient, physician everyone in healthcare. So how do you feel that the fear of litigation has shaped the way physicians practice medicine today? Oh, it's had a profound effect. And it, has had a m- a very profound effect in some sp- some specific specialties, like the emergency room for p- for example. This is where the story came from. A woman who goes in with a headache and ends up getting several thousand dollars worth of tests when she knew the, she knew what she was having. She had a migraine. All she needed was some medicine for it but the ER doctor had recently been sued for a person who had come in with a headache, and he discharged and then died, and he wasn't gonna let that happen again because the lawsuit was ravaging his psyche, so he wasn't gonna let that happen to him again. So he, his policy then was that you come in with a headache, you're gonna get a CAT scan, an MRI, and a whole bunch of other stuff. But there's lots of estimates, but some estimates are that physicians may order ... 50% of the tests that, that physicians order, order may be driven by this need to avoid litigation. Think about the magnitude of how many billions of dollars we're spending unnecessarily. Look, Look at this whole thing, Jean, with preoperative evaluations. Take a perfectly healthy person or even if they're elderly but they're healthy, and they're gonna have a cataract operation, and they have to go get a cardiologist to look at them. In some cases, the cardiologist order stress tests and all kinds of stuff for a freaking cataract. it, It's just we've risen to the level of, of absurdity in, how much we try to protect ourselves. And the reality is that you can't anyway because no matter what you do, no matter how much you document, no matter how many tests you order, we're still susceptible to this lawsuit problem Yeah, it is. It's such a slippery slope, which is chasing fear often is, you just- Yeah ... think it's quell one, and then another one pops out. It's like weeds. Yeah, absolutely. Very. So in the fourth story, the rise of the administrators you know, the bane of existence for many, many physicians. This is about, Mrs. Lopez, and you describe the growing influence of administrators in healthcare systems, and I think I've seen a chart over the last five to 10 years in how like, the number of physicians has kind of stayed stagnant and maybe decreased a little bit, but the number of administrators in healthcare has like, gone up, like crazy. Over your career, how has the balance of power shifted between physicians and administrators, and what does that mean for patient care? the, the, uh, Shift has been very dramatic and it has been during my career. I'm, in the beginning of my career, physicians had fairly tight control over the practice of medicine because most physicians were in private practice. They own their practices. They made the decisions about how to take care of patients. They had hospital affiliations, but the hospital didn't own them. They rounded in the hospital, but they didn't derive direct financial benefit from the hospital from the hospital's revenues or profits. And so it was a fairly insulated profession, and we were able as I said earlier, to practice medicine the way we wanted to practice it what happened was that with the increasing amount of regulation and bureaucracy and complexity and cost of medicine, physicians began to believe that they couldn't do all the administrative stuff themselves, and they began to hire people to do it for them. So we created these administrators and it's kind of like a Frankenstein monster. We created these people, and then they began to take over. And the real big change came when practices started getting bought by either private equity firms or by large healthcare systems, which meant that physicians in effect, had no more... Not only did not have any autonomy, but they also didn't have any power, and increasingly subservient to people who were running the healthcare systems but really didn't understand the core business. So as I said in the book this term administrative harm comes because we have people who are making decisions about how healthcare is going to be delivered without really understanding anything about the core business. And as you pointed out- Very appropriately, they've propagated very dramatically so that we now have legions of administrators, well-paid administrators who are doing things that frankly I really wonder whether we really need. And one of the things that came up in one of the stories was this woman who had a completely awful experience in the hospital was getting ready to get out of there and was stopped by a patient experience administrator, somebody who was, charged and paid to try to make patients' experience better. Well, The way you make patient experience better is by having more nurses and by having more people actually taking care of the patients, not asking them whether they had a good experience or not. So the irony is that we have a lot of money in the system, we're just spending it on people who are not delivering the kind of care that patients want. Yeah. Yeah, and I could talk for a long time about this, but I have a... I wanna get to the other stories which i- is this direct-to-consumer drug advertising, another bane of the existence of many, many physicians. So this is Mrs. West and Dr. Shah, and this story addresses this direct-to-consumer pharmaceutical advertising. You know, we see advertisements for Ozempic and Wegovy and all the different medications on TV all the time. How has this advertising directly to patients changed the physician-patient relationship and decision-making in the exam room, in your opinion? It's not helped anything, that's for sure. I was recently interviewed about this and one of the quotations that they took out of the book Was if you-- think about this. If you had a very serious cancer, okay? And you were going to see an oncologist, and then you watch television one night and somebody came on and said, " if you have this kind of cancer, you should take this drug." And then at, at-- if you had to go to your oncologist and tell your oncologist about the commercial and ask them if you should get that drug, then you probably should get another oncologist. Yes. Right? Because how could your oncologist not know about that drug or have considered it for you and m-maybe decided that it wasn't appropriate? And that's exactly what happened in the story, right? The person insisted on getting a drug that they saw on television. The the oncologist said, "That's probably not such a good idea because of your clinical profile." She insisted, he relented, gave her the drug, and she suffered the consequences of the drug a very toxic effect of the drug. So, another thing that they say on the commercials, these things are almost absurd. If you're allergic to the drug, you shouldn't take it. And they say that. I mean, that's part of the commercial. I mean, it's-- it is drivel nonsense. If you have a good doctor, you should not have to go and ask these kinds of questions. I have no idea. I've asked industry representatives re-repetitively, " th- do these commercials actually drive the market? D-do you think that putting a commercial on for a device or a drug that costs a tremendous amount of money and is a highly complicated issue, does that really drive the sales of the drug? Does that provide some profit for the company? What is the benefit here that accrues to all of this advertising that goes on for... And are we improving patient outcomes in any way by having these commercials on television?" obviously there, there are no data. But as bad as that is, Jean, as bad as prescription drug di-direct-to-consumer advertising is, what's even worse is advertising worthless drugs on television. Drugs that have no evidence of clinical benefit and don't re-meet the standard of a drug because they're considered a food substance. And there are many examples of this. I mean, Prevagen, for example. There-- if you go back and look at what are the data to support the efficacy, there, there's no, there are no data to support the efficacy. All you really need if it's a food substance is for a couple people to say, "Yeah, I took that stuff and it really worked well." And that's the level of evidence that gets it on television and advertised. And think of the hundreds of billions of dollars that are being spent- on worthless drugs that are not only worthless, but in some clinical situations, as we- another story in the book told about the guy who had the drug interaction by taking olive l- olive leaf extract. Sound like a benign idea, but interacted with a drug that caused him to have some severe bleeding. Yeah. It's a bizarre, bizarre time. Yeah ... the, the, the advertisements are getting... I think I saw someone's, an advertisement for ivermectin last- Oh, yeah. Yeah ... 'cause people are like, "You need a parasite cleanse." Like, what? Yeah. Like, People think cancer doesn't exist anymore and it's just parasites. Yeah. Yeah. The misconceptions that are fostered by these... H- how did put, how does putting a copper belt around your waist get rid of your back pain? I mean- Placebo. Yeah. Of course. It's a very powerful... most of the stuff that they're doing is promulgating a placebo effect. Yeah. And if you have enough people, Brett Favre or some you know, pro football player tells you that it's gonna work chances are it's gonna work, but not for long and not forever, and probably not for real. Yeah. So the last story I wanted to talk about is physician burnout, something near and dear to my heart. This is Mr. Han and Dr. Rob. And you explore physician burnout, which many now describe as a crisis. I do think it's a crisis. I you know, not maybe even just i- in the whole, as a whole, in the whole, if you're looking at medicine, but you know, looking at talking to individual physicians who love what they do, just passionate about the art of medicine, taking care of people, and then feeling so torn because burnout is, profound it's a, become a catchphrase but it's a real thing affecting people. So what do these stories reveal about the real drivers of burnout and how it truly affects patient care? Yeah. what you said there's a lot of truth to what you said. It's the people who have practiced medicine at, who, at a very high level, they put their heart and their soul into their work, they really are dedicated to patient care, they really give a crap, right? Those are the people who are most susceptible to burnout because they can't maintain that high quality in the current environment. So a- an example is think about this, Jean. think about a very dedicated primary care doctor who's going, who's get, comes into the office in the morning and is going to see 40 patients in about 10 hours, which is about 15 minutes a patient, if they're lucky, 10 or 15 minutes, during which time they have to deal with every disease that the person has, all of their medications, all of their test results, all of their questions, all of their anxieties and produce some kind of a record of the encounter an enduring record, right? Like a letter or something. They have to deal with the AMR. It's impossible. It's impossible. You can only do that if you are, if you're just skimming over the surface. There is no way that you can provide in-depth care to somebody in a 10 or 15-minute visit. But that's what our administrators, that's what our healthcare systems and private equity who own these practices demand because that's how they make money. And so they're, they are burning out the doctors who really care. Now, there are, there's a whole new set of doctors coming through the training system, young people, who are very much more accustomed to this kind of surface approach to patient care, who aren't used to sit, to having that same kind of dedication, and are perfect- and are reasonably comfortable with all of the demands that are being made on them. And so I think what we're gonna see over the course of time is that burnout is probably going to burn out. I don't think it's going to keep going because we're going to produce doctors who don't burn out because they don't really, they don't really care as much. It's sad, and I think patients are going to be very unhappy about it. I don't think they're gonna like the quality of the care that they're going to get in the years to come, but I think that's where we're headed It's, I don't even wanna think about that honestly. you know, I'm 50 years old and I feel like that's what I'm gonna be facing, but I would just say it to everyone out there, you want to find a physician that is gonna care deeply about your wellbeing holistically. Yeah. I don't know. I don't know. I think it's gonna be, in this, we're in this post-pandemic world, I consider it still post-pandemic, I think it's gonna be interesting to see how it unfolds. The concierge concept comes directly from what you just said, which is if you have a lot of money and you're willing to pay extra, you can get somebody that'll spend more time with you and be available to you and help you. But if you're a common schlepper right, that doesn't have a lot of money, and that's another story in the book, as you'll recall. That is the story that you're referring to. The pe- the people couldn't, they couldn't afford concierge, and so they ended with care that they, that was definitely not as good as what they had with their original physician. It's so interesting because you know, I, I travel a lot for my job now and, there are sometimes delays in, in traveling uh, especially in, when you're flying. And this individual, and I was just chatting with them in the airport as I was trying to, my flight was canceled, trying to get on another flight you know, all of these things, and, this individual said to me, "It's easier when you have money." It's ridiculous, right? Yeah. I mean... Yep. Yep. Abso- money talks, no question. Yeah. So the final question, you've spent decades practicing medicine, as we've said, and reflecting on all of the systemic problems in healthcare. If you were put in charge of fixing the US healthcare system tomorrow, what's the first thing you would do? I- it's actually, it's actually pretty simple. It's a simple answer, but a very complicated task. We need to have a system of healthcare in the United States that permits every person to be able to access care. And the people g- use different terminology for this, Medicare for All or universal healthcare or social med- socialized medicine, whatever. You can use whatever term you want, but everybody in this country needs to have access to basic medical care, so a primary care doctor, be able to go into the emergency room and have it paid for if they have an illness, be able to get their medications without having to get a second mortgage. Everybody has to have that. We need to pass legislation that allows all of our, all of the people in the United States to have that basic insurance. Uh, Now, like in many other countries, if you want to enhance that and get another level if you have the resources to do that, fine. You can embellish it. But we can't keep going on pretending that this patchwork system of payment for medical care is working. It's not working. It's falling apart, and the current administration's throwing gasoline on the fire by cut- by massive cuts in the social programs that are available to people like Medicaid and Medicare and the Ve- and the Veterans Administration. So I think that's what we need. What the... There's no other solution, and if the people in power in the legislature don't have the stomach To admit this and to work on it and to get it done, then we need to replace them. We need to replace them with people who really thoroughly understand the need for universal healthcare, because as you know, Jean, we're the only developed country in the world that doesn't have universal healthcare that, that has this crazy, crazy system of trying to take care of people and disadvantaging so many of them. Yeah, it is a crazy system, and I hope you get your wish one day. Hope you're put in charge. It is a wish, Jean. It is. I, and I understand, and I'm not pr- I wouldn't pretend to make it sound like this is a simple solution. It's not simple at all. It'd be, it would be hard to put it together, but we gotta start. It's not reasonable. It's just not reasonable to put people at risk. we are sentencing people in this country to early death by not doing the right thing with their medical care, and it's way, way past t- due that we need to make the changes that will benefit our patients. I agree. So if people wanna find out more about you and your book how can they do that? It's very simple. It's peterkowey, K-O-W-E-Y, author.com. That is my website. The website has a whole bunch of information. We pr- provide links to a number of great podcasts like yours that I've had a privilege of participating in, in interviews. I interact with people on the website, so if they have questions you know, I go on and try to help them with their answers, and it obviously has a lot of information about the book itself and how to get it, although it's very easy to get on Amazon. So yeah, peterkoweyauthor.com is the best link. Excellent. I encourage everyone to check out the book. It's enlightening. Dr. Peter Kowe, thank you very much for joining me today. I really enjoyed the conversation. Yeah me too. I think it, it did a great job, and as again I'm very appreciative of your willingness to take on these, tough topics.

Thank you for tuning in to Taking Healthcare by Storm: Industry Insights with Quality Insights Medical Director Dr. Jean Storm. We hope that you enjoyed this episode. If you found value in what you heard, please consider subscribing to our podcast on your favorite platform.

If you have any topics or guests you'd like to see on future episodes, you can reach out to us on our website. We would love to hear from you.

So, until next time, stay curious, stay compassionate, and keep taking healthcare by storm.