Suck It Up Buttercup: Challenging the Status Quo in Healthcare

In this episode of the Caregivers podcast, Dr. Mark speaks with Dr. Todd Otten about the challenges faced by caregivers in the healthcare system. They discuss the importance of caregiver wellness, the impact of burnout and moral injury, and the need for solidarity among caregivers. Dr. Otten shares his journey in medicine, the creation of the documentary 'Suck It Up Buttercup', and the role of organizations like Medicine Forward in advocating for change. The conversation emphasizes the power of kindness, the importance of self-care, and the potential of AI tools to assist caregivers at home.

Support Dr. Otten:
Medicine Forward: https://medicineforward.org/
Suck It Up, Buttercup: https://suckitupbuttercupfilm.com/

What is The Caregivers Podcast?

The cost & courage of caring - stories that spark resilience.

Speaker 2 (00:00.27)
Welcome back to the Caregivers podcast. I'm your host, Dr. Mark Ropalesky. I'm excited that you are here and it as always will be a privilege to host you for the next while as we explore some new topics and new ideas today that apply to caregivers everywhere. Before we get started today, I just wanted to remind you and once again thank you for following the show on YouTube and you can listen in on Apple podcasts and Spotify. Just want to sort of take the time to thank

our viewers on TikTok and Instagram and their engagement. We want to hear what you have to say. Your thoughts are going to shape our direction and our direction is really to provide as much of an inclusive platform for us to engage as caregivers and share thoughts and share stories and impressions so that we feel there's a place for caregivers on the global thought stage. And today's episode, we have an amazing guest, Dr. Todd Otten, who has been on a journey from

training and surgery to the Navy, to family practice, and the bumps along the way that shape caregivers and clinical practice and the challenges such as burnout and moral injury and then rising from the ashes to be an agent of change. And no more better example of an agent of change can be the movement that

Dr. Otten's helped catalyze through his input through Medicine Forward, which you can learn more about at medicineforward.org, but also his upcoming film and group project called Suck it Up Buttercup, which is an exploration of the situation of US healthcare and the risk of imminent demise of caregivers, patients in the face of incessant greed, and most importantly, profits over people.

So it is a great thrill to welcome Dr. Otten to the podcast today. And I can tell you, you won't be disappointed. Welcome everybody to the Caregivers podcast. We're thrilled to be here today. Thank you for all of you who have been tuning in so far, our new subscribers and listeners. This is a really meaningful project for me and my team and certainly very meaningful to have our guest today, Dr. Todd Otten.

Speaker 2 (02:17.868)
Welcome, Todd. It's amazing that you've found the time to spend some time with us as your story is important to share. And I think no matter what kind of caregiver you are, you're existing in a system today that no matter what continent you live on, you're feeling the drain and the pressures. And the hope is that we can, moving forward, collectively understand where we situate ourselves as sort of a global nation, if you will, of caregivers.

and where we can start making differences. so I'd like to maybe start by giving our viewers and our listeners a little bit of an introduction about Todd. And Todd, you can jump in if I have any details wrong, but we have trained extensively in medicine, but often our journeys take us in different paths. And certainly after graduating from medical school in Detroit,

Dr. Outen pursued some surgical training before then pursuing dedicated work in the Navy as a flight surgeon and then realized that his calling was not to stay in surgery, but rather to pursue further training in family medicine where he became a general practitioner in family medicine with an illustrious career having built and monitored various systems and been at the forefront of really understanding that

dichotomy between the quality offered to the patients and ideally to the team and the team of caregivers involved in patient care and the demands of the system. And it's certainly been, as you captured in your book, a incredible journey and lots of lifelong lessons, some of them difficult and, you know,

We've both been there, actually, I think in the same year where we had to both take a step away from what we were doing and needed to sort of retool and revamp and re-explore where we were headed next. And fortunately, Dr. Outen has been able to redirect some of those energies that kept him well-fueled in practice and building the endeavors that he did.

Speaker 2 (04:31.68)
over the years and has now directed that to some amazing causes. And we are really thrilled to be able to explore the Medicine Forward Project and an important film that's being made in which we're happy to be a contributor to and support Sake de Buttercup, which is available to view on trailer. And we look forward to seeing the final product, which will no doubt be eye-opening and direction shaping.

and really important to propel things to the next level if we're going to try and change something and incorporate caregiver wellness across the board, but also patient wellness in the caregiver context and in the caregiver interaction, which is just so important, which you've so beautifully illustrated having.

teamed up with this companion offering, which was your book, Ripple of Change, that was written by you and a former patient of yours who really made important contributions and really reflected the dynamic sort of importance and uniqueness of the patient-physician relationship. And to see that translated into an endeavor with the mission in mind is spectacular.

So maybe I would, is there anything you wanted me to clarify or you wanted to clarify in terms of your trajectory as I've outlined it? If not, we can sort of launch and move forward.

Well, first, guess, thanks for having me. It's an honor to be here. And when I hear these intros, sometimes it's almost a little surreal. Like, are they talking about me? Did I do all those things? And I think, honestly, you pretty much nailed it. I think the one interesting thing that maybe for clarifying for people is being a flight surgeon is definitely a bit of a misnomer. It's really primary care.

Speaker 1 (06:21.384)
And so that's where I really learned to love family medicine. no, wasn't, people always ask me, were you up in a F18 doing an appendectomy and things of that nature? And the answer is no. It's a great title and it definitely grabs people's attention. You know, and I'm proud of my, you know, the wings I earned and all those things, but the reality was it was a critical moment for me to really find my true calling, which was primary care. And then,

Is it? Yeah.

Speaker 1 (06:50.08)
The rest of it, I think you're spot on.

So are you actively still seeing patients these days or have you retired from clinical practice completely?

Yeah, yeah. So the answer is kind of sort of maybe yes all the above is how I'll describe it or start it off. So when I initially stepped away in 2022, I quote unquote retired. And I think that was probably premature saying that. mean, you know, I have endless energy and things I want to do and accomplish. So I think in my heart, I knew I wasn't going to just step away completely. For about a year, though, I didn't see patients at all.

I spent the time finishing writing and editing and then publishing the book Ripple of Change, which then in and of itself was an amazing journey. But then I sort of transitioned into a career 2.0, if you will, got into networking, learning how to network kind of on the fly, getting into advocacy circles, getting connected with all these other amazing groups that are out there. But after about a year away from seeing patients, I missed it.

You know, I really missed that interaction. the euphoria that you get from helping another person is almost hard to put into words. And so I looked for a way back, but on my terms, you know, not in this RVU revenue churning machine that is healthcare in the United States. And so I reached out to a very forward-thinking physician-led ER group.

Speaker 1 (08:24.808)
And you know, what is a family physician going to do in an ER? Well, they're looking to provide care outside of the walls of the ER.

Continuity is so important, you're right.

Yeah. And so there's all kinds of amazing things they let me do. So to answer the question, I do a little bit of what's called a chronic disease management. And ultimately what that is, is somebody who's struggling to navigate the system or they've got a complex issue or perhaps there's some side effect that hasn't been picked up on. I can spend an hour, hour and a half with them and really dig into the, trying to find the root cause. And it's been amazing for the people that I've seen. I think I've really been able to help a handful of folks.

I agree, it's episodic. see maybe a couple people a month on average, I guess. But it's those touch points that kind of rein you back in and remind you why you love the profession so much. So it's definitely a privilege to be able to do a little bit of direct here still.

Absolutely, and it plays such a vital role for individuals who don't have a primary care provider where especially if they show up in an urgent care setting or an emergency room and the default would be well, we'll refer you to a specialist, but the wait list is a long time. It's just simply because they don't have a quarterback for their own chronic care that plays such a valuable part in sort of managing the patient within the context of the greater system. Well, it's nice to hear that you're back seeing patients and having that

Speaker 2 (09:52.206)
part of your personality and that part of you, still benefits from doing that sustained. But tell me a little bit about in 2025, like what do you care about the most these days? You've been on a journey since 2022. And I think that was when the office utopia sort of

fizzled and that was the day the music died and we'll get back to that later on perhaps. But what do care most about these days, Tom?

Speaker 1 (10:25.838)
If I had to put it in a word, I guess I'll tell it in a bit of a story. One of my heroes in healthcare and trying to reform healthcare for the better is Don Berwick, who was with the Institute for Healthcare Improvement, was the head of CMS Center for Medicaid and Medicaid Services under the Obama administration, one of the originators of the triple aim.

And we were privileged to do an interview him for the, you know, the pending documentary. And I asked him the question, you know, given the limited knowledge of what we're trying to accomplish, what would you call this film? And he said solidarity. And I was like immediately transported to nerd heaven at that point. Like I've been so excited for the rest of the day. And back to your question, I think it speaks to what I'm jazzed about.

And I'm jazzed about breaking down silos, breaking down barriers, having conversation and realizing that healthcare delivery is a team game. And part of that team includes physician, nurses, APPs, but also the patient and the caregivers. It should be a cohesive unit that's working together. And so that's part of the answer. But I also think the groups that are trying to reform things or make things better

We need solidarity there too. I can't tell you how many times I've seen groups where they're literally trying to accomplish the same thing, but the comma in their two mission statements is like one word apart and they can't figure out how to work together. And that's problematic. It's very problematic. mean, we have long standing, well funded, what in the United States, at least well lobbied organizations that are happy making a lot of money.

And we've got to learn to work together on many, many issues. yeah, and I think that speaks to the work that, you the project with the documentary and really what we're trying to accomplish.

Speaker 2 (12:33.934)
Why does it matter so much at this point in time? mean, we read the headlines every day something's popping up on the major news wires about a crisis in healthcare and it's not just in the US. We're facing it here in Canada. We're hearing stories out of the UK and I'm sure no matter which jurisdiction or which continent, there's a certain flavour unique to that area, but there's a resounding commonality of the message.

Speaker 2 (13:05.91)
What's driving this at this point in time? mean, have we truly hit a point of not only are we siloed, but down in, whether it's in the ER or in the clinics, are we in the war zone, so to speak, as some people describe it between, you know, risks of violence, ongoing burnout,

just a feeling of sort of unsustainability among physicians, nurses. mean, from what I've read, the shortages are going to be persistent. People are abdicating from healthcare providing, not just physicians, but all kinds of healthcare providers. mean, are we in this clutch moment right now where it's like, do or die, we need to get this message out there. This movie needs to be aired. Lots of people need to see it because it's going to be the wake up call that...

has not embraced everybody yet, but will be the big catalyst.

Yeah, there's so many directions we could go with this. know, Mark, think, do I hope and pray that this is the wake up call for a lot of people? I do. I think, at least in the United States, and I think, you know, elsewhere too, I don't think the average citizen is truly aware of the harm that's occurring within a system that's supposed to be healing.

You know, in the United States, the number of adverse events or medication errors or deaths related to medical errors, I'm not going to spout out numbers. can look at this, but they're not small. You know, we're talking in the hundreds of thousands, most of these issues we're talking about. This is system where we're supposed to be helping people. You know, we are having adverse events at the rate of, to quote a friend of mine, having 10 jumbo jet airliners crash per week as an equivalent.

Speaker 1 (14:59.746)
Would we stand for that? No. I mean, you hear one airline, airliner crash and it's national news. I mean, we're killing people on a daily basis with the things that are going on behind the scenes. And the average person needs to be aware of that. And why? Because we need those voices. We need that, power, the power of numbers to move the needle in the correct direction. You know, and I guess to take it back from a personal perspective, why am I so driven about this?

I often talk about three components. know, obviously burnout is a visceral, painful experience, depending on how far you got on the trajectory with it. And we don't need to get into that, but I've also had four of my colleagues die by suicide in my career. You know, that's insane when you think about it. Like, people are so frustrated that the only way they see out from their pain is to end their own life.

I mean, what the hell are we doing where that is the solution, right? And then you think about the patients. When I was seeing patients full time, there were some days I would spend more time trying to just calm people down about their frustrations than dealing with diabetes or hypertension or congestive heart failure or depression, whatever the case may be. Sometimes it gets to the point like, look, I respect all your concerns, but I can't fix all that in 20 to 30 minutes, right?

Like we need to take that to another level. Unfortunately, I think I've kind of gotten myself into a position to maybe start to do some of those things. And not just me, but rather a way to collect. That's how this is going to happen. It really is. I know that was kind of a long winded sort of circuitous answer. Sometimes they go off on these little tantrums.

It's broad-based, but you can see where the applications go. while your colleagues may have been physicians, I'm sure there's a nurse listening somewhere who knows of someone who had a similar fate, or we've all met social workers who were burned out and can't cope anymore. we all have quiet ideas at times, but we don't always follow through with them. But the risk of trauma is certainly there.

Speaker 2 (17:18.561)
I think burnout can be a fatigue factor which may result from professionally, no matter what you do, but just not knowing how to manage saying no. But what drives people to that next level, as you describe, which should have been traumatizing to experience that with your colleagues, is that notion of moral injury, where morally you feel you're being subjugated to...

decisions you have no control over that are just wrong. They're wrong for you as a caregiver, they're wrong for your patient and you feel sort of powerless, but yet you keep enduring through them. And I know a lot of your work has dealt with the growing concept of moral injury and certainly champions like Wendy Dean are important voice to bring that to the forefront. And I think it takes on different flavors no matter what healthcare system you're working in, but.

When you feel that and it sort of mounts daily and it's always present, that's worse as far as I'm concerned than any burnout. In burnout, you can recover from pretty systematically with a set of tools, but moral injury that's recurrent and persistent day to day is eviscerating.

I agree with you. And when the evisceration is happening by a thousand micro cuts, till eventually you're, I this isn't too graphic, you know, your abdominal organs are all over the place and, you know, it's horrendous. I mean, that's just this repetitive insult over and over and over and over again. And it's emblematic of problems that we don't have a lot of control over that are much further upstream. You know, and Wendy,

does an amazing job talking about moral injury and being a champion for that. And I agree with her. In fact, one of her quotes in her book, if I betray these words, physicians, we're canaries in the coal mine. We're at the tip of the spear. We're the patient facing, oftentimes the patient facing component of a health care system that is toxic or not supportive or completely focused on money.

Speaker 1 (19:29.974)
or full of greed or other nefarious things, the list goes on and on and on. And yet we're supposed to be the ones that are helping people. it's a borderline lunacy when you're not given the tools and the staffing and all the other things you need to give the human being in front of you the best that you can. It is so, so frustrating. I to the point with like prior authorizations.

I would get so frustrated with doing some of them that I would start to do them in really radical colors just to try and get the attention of the person on the other front reading them pink and purples. And I think I used green and then they told me I couldn't use certain colors. I think at one point I used a Sharpie marker. I'm quite certain I used a crayon a couple of times. I never went to lipstick, but man, that would have been a great idea. Smiley faces on there and all these sort of

Stay.

Speaker 2 (20:23.726)
I'm go.

Speaker 1 (20:27.456)
semi passive aggressive things to try and catch the attention of the person on the other end saying, you know what, this isn't okay. This is not okay that I'm having to justify a medication that has kept a patient with severe congestive heart failure out of the hospital for six consecutive years. Why am having to justify this every January 1st? mean, the amount of money we, it was mind blowing and that would be just one.

Imagine like a stack of these things would show up in your office every January. It's mind-numbing, the paperwork drill.

That is, and really what you're describing is almost like cognitive dissonance. The type of dissonance we experience, you know, in different other settings of sort of abusive relationships where things just don't add up or you're starting to second guess your recollection of like, how did things really occur? And maybe I was the one who had, maybe I'm the one who has it all wrong, but no, it's dissonant. to your point, I mean, we, you know, in GI, we have various

know, medications that are regulated, et cetera. And I've got, you know, taxpaying citizens whose medications keep them from being incontinent in the supermarket. Yet I need to justify with three letters back and forth ongoing coverage for them. And these have been taxpayers all their lives. Like they've paid into our system yet somewhere they, you know, there's someone who feels that they're not entitled to it unless I justify it and need to, as you say, renew it. it's quite the game, but

On that idea of dissonance, as you started off your career and were in family practice, when did you realize that you were starting to hear dissonance and maybe your vision as how you had planned it wasn't going to quite turn out the way you planned? Were there some key pivotal moments? Because we have a lot of young listeners as well. We have caregivers out there and we have caregivers in training. And I think part of

Speaker 2 (22:30.094)
the mandate of our project is not just to think about the moment, but think of the next generation in the pipeline. They need to be so resiliently trained. And there are individuals who are debating now whether we're really training our future caregivers, matter whether it's in medical school, nursing school, school of social work, or...

PT, OT, and the burnout literature is available on all of those domains, but maybe we should be treating them like Navy SEALs. I shout out to Mark Bonta, who's ditched the lab coat podcast, recently featured a guest who was talking just about that. Like our caregivers should be trained in all of the skills of resilience to be able to enter the healthcare domain of today. And yet many argue we're not really offering that to them.

But when did you realize in your trajectory that things were not quite as you expected them to be? And what were the costs as those started to amass leading to your first sort of experience with burnout?

There were probably multiple episodes where I started to appreciate that. think ultimately I was probably the frog who was in the water that it was slowly being turned up, the temperature, then ultimately I was boiled and it went pretty horrendous burnout. I can point to a couple key moments where the decisions that were made were not right and very much financially driven.

and had a downstream effect, a significant downstream effect on multiple levels. And then actually you allude to a couple of them. One was, or alluded to a couple of them earlier rather, from Ripple of Change. One was when I had about $3,000 of pay with health because I had two incomplete charts. I mean, literally a medical assistant had to check one box in each chart for them to be closed. That's it.

Speaker 1 (24:36.384)
It took less than 60 seconds, yet for some reason the administration thought it was okay to withhold $3,000 of pay because that particular day they did chart reconciliation. had two open charts. I mean, at the time I was chief of staff, I was a medical director for an ACO doing all these other things, seeing like 6,000 visits a year. I was not a habitual offender for incomplete charts by any stretch of the imagination. The fact that that decision was made was borderline lunacy.

in my opinion, there was a complete disconnect between administration and the physician clinician side of the house. And I even appealed it. I said, I don't think you really understand what you're doing with this. Like, this is not what this is for. This is for the people who have hundreds of incomplete charts, and you're trying to make a little bit of a financial penalty. So they'll keep up on that a little bit better. One of the other big moments was the day the music died.

When they were going to move me, I had recovered from burnout, things were going well. You know, we worked in the office utopia. It was magical. You know, the caregiving team, the nurses, the people doing registration, the medical assistants, the practitioners. We didn't lose anybody. The retention was through the roof because we had a culture that respected wellness and human lives and didn't treat people like robots. And occasionally I would push back against administration.

and they would get angry at me and I probably would show them a specific finger and move on. And that's just how it was. We put a little bit of a bubble around it, but they made a decision to save money on rent, which was a disaster for that clinic. Of the 15 people that worked there, nine months, excuse me, four months later, nine of those individuals had left the system, including one physician, two nurse practitioners, a handful of medical assistants. You talk about a lot.

loss. And those are people who were trained to perform according to the quadruple aim, which we'll get to in a moment. And those, the amount of time invested to train someone of that level of quality to deliver care as part of a team under that umbrella of dedication to intercollegial wellness and also patient wellness and the whole experience. mean, you alluded to it in your book and I've read about it elsewhere as well that

Speaker 2 (26:52.142)
I mean, that's a huge indirect cost of, know, people like that and coworkers like that in an office setting don't appear out of nowhere. They need to be groomed. They need to buy into a culture. They need time with the group. They need time with the patients and eventually become this amazing machine. we've talked to mention it a couple of times, but I think just for our listeners, the office utopia was basically this beautifully oiled machine that arose from the application of

quadruple aims of the quadruple aim, incorporated caregiver wellness along with the originators of the triple aim. maybe we can speak, tell us a little bit about the quadruple aim and how it really resulted in you building this amazing office system, which you witnessed in the blink of an eye or a tick of a management box suddenly dissolve.

Oh, yeah. Wow. So I was first introduced to quadruple AIM, I want to say about 2016. And the quadruple AIM was an evolution of the triple AIM, which is really centered around population health. And I try and simplify it for people that it's easy to grab onto. Quadruple AIM think patient experience, quality care, lower cost, but also that provider wellness. And I appreciate that some physicians do not like the P word. I totally understand that. So substitute a clinician, caregiver, use whatever works in your

you know, your arena, if you will. But ultimately, when you really pay attention to those four elements when you're making decisions, the majority of stakeholders win. I've seen it work. I've seen it work at the office level. I've seen it work at the hospital level. I've seen it system level. I've seen it work at the ACL level, which is, you know, tens of thousands of lives. And you're never for want of patient volumes.

for the principles that are outlined because you are caring for people. You're seeing them as a human being, not as a widget. You're seeing your colleagues as a human being, not as a widget. And the amazing part of the quadruple aim is you end up saving money for a whole host of reasons that have been outlined. And I'll give you just one example without getting into the weeds too much. In the United States, the average cost to replace a physician is

Speaker 1 (29:11.914)
Somewhere in the range of $500 to a million dollars is typically what's quoted. I have a feeling that number is starting to tick up because you're having to replace people with low-cum-settlements, it's more expensive, all these other things. If your wellness efforts and your system or what have you cost a quarter million dollars and you can retain one physician because of that, it has paid for itself. Not only that, but the errors go down, burnout goes down, expenses tend to go down.

The winds are just everywhere. The problem that the C-suite has is there's not this super tangible ROI all the time. It's all these dozens of intangibles that you end up saving on, which is why it's such a powerful framework that I'm thrilled that we're starting to see more adoption of it, to be honest with you.

So when you speak of return on investment or ROI and when your administrators or where administrators anywhere might be calculating them, do they factor in the indirect costs and indirect advantages or indirect savings or is it always just the direct? Because exactly what you're describing, a healthy functioning caregiving unit benefits from all of the indirect advantages or indirect savings. But if no one's calculating them or factoring them in,

It's just like the notion of some of the new biologic drugs, right? If they keep you out of hospital and they keep you away from expensive procedures to manage complications along their natural history, then that's a win, even though there's upfront costs, the indirect cost savings, even if you include work absenteeism. And to your point, if you've got a group of 10 individuals working in a busy clinical office providing the best care to the individual in a healthy environment,

Those people are not going be calling in sick unless they're really sick. They're not going to be burned out and using sick days. They're going to want to show up. there's a huge cost savings in that. But if no one ever calculates or pays attention to that and it doesn't factor into the bottom line calculation, then we're really not getting an accurate representation of the power of what the quadruple aim really has to offer.

Speaker 1 (31:27.926)
I agree with you 100 % Mark. I think it's, there's probably a couple of ways to answer the question here in terms of what percentage of institutions, administrations, C-suites actually factor that in. I don't know that I give you

I just asked you what's C-suite for our listeners just so people understand.

Sorry, the executive suite, CEO, CFO, COO, that kind of nature. You know, I think the ones that are factoring it in are the brilliant ones. And I think they're the successful organizations. And I think they're the ones that have a good culture and have good retention and all those other intangibles that we talked about. But I also think they're in the minority. I think the majority are very hyper focused or have this myopia, if you will, on

the ROI in three to six months, very much from a business model or lean model where how can we be the most efficient to get the most people through? We're not building cars. We're taking care of human beings. And their biggest issue might be where's their next meal coming from? If they don't know where their next meal is coming from, all this other stuff that we just outlined doesn't mean squadoosh. Actually, I'll

throw back another simple thing, an idea, if you will. One of the chapters in Ripple of Change really revolved around the quadruple aim and implementing the quadruple aim and what does it mean and how can you use it as a framework? And I was thinking like, how can I create kind of a fun way for people to wrap their head around this and try some things out? And so what I ended up doing was I created 10 low cost or no cost challenges.

Speaker 1 (33:13.486)
If you will. Yeah, I titled the chapter ROI for a health system. And there was a lot of tongue in cheek things in there, I would say, and a lot of, you know, stories where maybe I was the bright child who was getting in trouble or whatever the case or some crazy Navy story. But really, I was trying to catch people's attention to say, you know what? This is cheap and we can do this. And oh, my goodness, we might be able to solve 37 other problems by just

I remember that chapter.

Speaker 1 (33:44.27)
smiling more, as it maybe is an overly simplistic example. yeah, if you're for some great ideas, well, obviously I'm biased, Murr, but if you're looking for some great ideas to implement some things, chapter 18, our life or health system is a great chapter to skip ahead to if I had to suggest one.

You know, just reflecting a little bit as you're saying that and thinking about the, you know, the different ways that, administrators may look at, ROI is et cetera. mean, healthcare is a lot less expensive than illness care. And, you know, there's the paradigm shift, right? and, if illness care is more universally accessible than healthcare, then

our population isn't as healthy as it should be. So I think there's, know, I've enjoyed reading your book and the best thing I've realized after just about finishing it is that I need to read it again, because there's so much about the second read that sort of you gleam out of things. you know, having made that transition that you alluded to earlier, where, if I remember your story,

When you came back from burnout, you had this opportunity to apply the quadruple aim and build this sort of office utopia, this really well-oiled, highly functioning, highly integrated group that took care of each other while they were tasked with taking care of their patients. And like, what an amazing framework to be able to build. can you tell me a little bit more about like how it felt?

You refer to it the day the music died and it's such a resonant, I mean, for those of us who love music, but it's such a resonant term because it goes back for so long and so many people heard it.

Speaker 2 (35:41.144)
How did you recover from that? That must have been, I I'm trying to internalize what that must have felt like. And yet here we are today and you're marching forward stronger than ever. And you're mobilizing a team of support with Medicine Forward and some amazing names there on your board of governors, as well as, you know, a incredible unit of individuals who are building the movie that hopefully is going to

change directions and collective thinking. Walk me a little bit through about how we got to today after the music died.

Well, I think the first part of it, so I'll maybe touch on this in three sections perhaps. So the first piece to this is how did we develop it? think it was leadership was important, collegiality was important, solidarity was important, belief, fortitude, sticking up for my.

self and for my colleagues in the office when things were being, things were coming down from on high that were kind of disrupt the beauty that we had created. I'll give you a simple example. Civic culture. So it was myself and three nurse practitioners were the clinicians and I had an open door policy. I loved to teach. They were right out of school and there was reasons for that. I didn't want to have to try and unwind what I considered to be

bad habits and a lot of times we'd be going over cases in my office, which looked like a little bit like a flea market with all these. Actually, I got some, I got a Lego over here, think from, let's see, I'll grab one of these. had one of my patients used to bring in and give me a Lego every time he came. And so I had a little collection of Legos in there. I had a Spider-Man pillow. There was a rainbow unicorn above my desk after one of my birthdays that stayed up there for like a year. But it was a warm, inviting,

Speaker 1 (37:46.686)
office. It wasn't this sterile, cold, white, medical, whatever that we're all used to. I mean, literally one of the nurse practitioners would be sitting Indian style on the floor while the other two were in chairs just because we all wanted to be together talking about patient care. That was torturing to not tear up when I talk about it because it was magic.

the zone of safety for learning and teaching and just.

Absolutely. Yeah. mean, the amount of sort of closed door conversations to say, you know, it's okay to not be okay. It's okay to not know everything. It's okay to ask for help. Like we're human beings. None of us are perfect. That's how that culture got built. And I relished it. And to be honest with you, when I drew a line in the sand on the day the music died, if you will, I never grieved that right away. I didn't grieve that.

that loss of that job and I didn't really realize it until probably about a year ago. I didn't realize how many things in my life I had never grieved. The death of my colleagues by suicide. It was when I started to understand all these traumatic things that I had never processed that I think my resolve went from, I don't know, whatever scale you want to use, but maybe we'll go to spinal tap and turn it to 11, I guess, is, you know, on the amplifier.

the spinal tap bands out there. And so my determination to make a difference went through the roof at that point. And I realized, I also realized I maybe had a skill set that I didn't appreciate before. And I embraced it. I embraced the pain. I embraced the mistakes that I had made. I embraced the losses. I embraced that clinic that I loved being gone. And used that as

Speaker 1 (39:38.368)
my fuel to go forward. And when the documentary project came around, it was like it was this dream. And it wasn't my dream. It was Mary Ann Wilber's dream. A geologicalist who stepped away that wanted to make a massive difference. And I got involved for a couple of reasons, including the funding mechanism and all that kind of stuff. But I was like, holy smokes, this is it.

This is the project that could touch millions of people. And when I realized that, I was all in. And I love it. And I think what we're building is, I hope it's something special and powerful that really impacts people in a positive way.

I hope.

Speaker 2 (40:24.014)
hearing for mostly and I know that you didn't do this alone and know you've got your boys and your partner and an extensive network of friends that you allude to in your book, but you went through some pretty radical healing to free up the space to be able to embrace medicine forward and the movie production with your new colleagues and to actually let go of the past. What resources did you turn to to sort of

go through that healing process? Were there any strategies that you employed or any resources you might put out there to sort of suggest for caregivers going through maybe similar patches, the tools that you found were really useful?

Speaker 1 (41:10.915)
Wow, there's... boy.

I mean, that's a big question. It's loaded. But anything that strictly comes to...

It's an amazing question. Please continue and then I'll jump back to answering it because I'm debating what level I want to go with on this one.

This is an amazing exchange and I'm really thrilled to be able to have it with you. But when I think about my own trajectory and the healing that it took to finally emerge feeling more firmly-footed and actually in a better place to rebuild and retool, it's not just doing a couple of checklists. I mean, it's a deep sort of healing process.

letting go and freeing up that space in you to actually take on new things and new agendas with new energy and a much better approach to self-care as you take on those new projects and new things to lead.

Speaker 2 (42:04.064)
So, and that's sort of what's sort of is behind my question is that it's not just, yeah, I read this one book and I was fine, or I took this inventory and now I wake up 10 minutes earlier and I'm cured. Like there's a big process involved and I think people and listeners may not appreciate the process involved, healing and letting go is such an important component to being able to move forward.

So in standard fashion of my previous office, my current office also looks like a flea market and a combination of somebody threw a small grenade in here. This is just one piece. I don't know how well you can see all these trauma recovery, the myth of normal, Bessel van der Cook's, know, the body keeps the score. Incredible books and I've got a whole other stat elsewhere. So back to the question.

wonderful.

Speaker 1 (43:00.288)
It was a bit of a, and I don't think, there's not one magic answer out there. It's gonna be different for everybody. Whether it's a trauma informed coach, whether it's spiritual, whether it's a priest or a rabbi or a friend or a colleague, I'll say this, you the words, connection mitigates trauma are so true.

You're absolutely right.

Speaker 1 (43:29.422)
you know, and I'm still working through it. I'm not going to sit here and tell you I'm 100%. I don't think I'll be 100 % the rest of my life. I think this will be a lifelong journey of dealing with the traumatic things that have occurred in my life from age of 12 to age of 49. But it was, I think, perhaps the one of the most important things that I was told was that you have to embrace it.

You have to embrace the pain. And you know, for decades I did anything but. I mean, I was trying to throw the pain out the window, stuff it into that little box, tuck that away into the corner of compartmentalization as best I could for decades.

which we've been trained to do well, right?

Totally and it has its place right like when you're trying to save somebody's life and doing chest compressions or putting in a chest tube or you know Say something went bad, you know in a colonoscopy or whatever you want to be in that moment and giving that person your best as a physician But that shouldn't be the end of this story If there should be an opportunity to come back and look at say, okay What went wrong? How does this make me feel and how do I attempt to heal from that and ultimately the person?

Speaker 1 (44:50.168)
that I don't think I've given enough credit to as my wife.

You know, it's been hard, you know, because when you're traumatized, who do you take it out on? You take it out on the people you love. You take it out on family. You take it out on friends. You take it out on cohort. And, you know, there's things in my life I'm not proud of, you know, and we all can say that. How do you take those and how do you learn from them and try not to repeat those mistakes and become a better person?

And I think there's two things I always tell people. Number one, look out for your colleagues. You have no idea who's struggling behind the facade. Like I had no expectation that I was going to be on the verge of tears doing this interview, but I think it speaks to you don't know unless you ask, so ask. You might save somebody's life. And the other part is don't be afraid to ask for help. If you're struggling out there, don't be afraid to ask for help.

I'm sure in your office, Utopia, there were a couple of times where people cried together and the togetherness and crying is huge. you know, I think of one of my earliest experiences as a first year resident. And a lot of those at that time in your life, you're dealing with death and people who may be a couple of years older or a couple of years younger than you. And I remember just losing it one day in the conference room on one of the oncology wards.

And the best thing was that one of my junior colleagues who was also a resident was right there. We were both looking after the patient and we cried our eyes out together. And you know what? Don't pick doing it alone. Find someone, whether it's your partner, whether it's your, you need a good cry and the best person around who gives the best hugs is your kid or your son or your daughter. Just don't cry alone. Don't.

Speaker 2 (46:50.164)
stay alone. And we're seeing so much more these days about the importance of debriefing as a team, because things will go sideways once in a while. It's the nature of medicine, and it's not automatically because of an act of omission. It's just we can't control everything. I appreciate your sincerity where you're coming from, because the healing process is long and

You can only build forward and can't reverse some of the times of the past when the usual compartmentalization process just didn't hold the fort and you start spilling over. I've experienced that and I know exactly what you're saying. it's understandable.

I think it speaks to opportunity too, right? the days of superhuman know-it-all positions and whatever label you wanna, we need to get away from that. We need to realize that I'm a human being, you're a human being, all caregivers are human beings and we're in this game together, this game of life together. And the more that we look out for one another and...

do random acts of kindness, the better off we're all going to be. Which, you know, it's interesting, and that's not even a good segue, Mark. I didn't think about it until just now, but I mean, ultimately, that's really what we're trying to do with the documentary, Sucking Up Buttercup. You know, for years, we've got this intergenerational trauma, particularly in medical training, pimping and asking questions and shaming and all the, the culture of silence, you know, the culture of

We need to get away from that. Like big time. Sucking up buttercup is not okay long term. Maybe short term and in little pieces, great. And the whole notion that we're not resilient enough, I forget that. People that go through medical school are super resilient. It's super competitive going through college, super competitive to get into medical school. Then you're competing in medical school to try to get into residency, try to get a fellowship. More realiency.

Speaker 1 (49:01.346)
More resiliency? Give me a break. Some of the most resilient people I know are physicians, including one that was a farmer's seal. I'm totally digressing myself as I normally do. Anyways, with the documentary, we are trying again to accelerate and impact the network, to get people talking, to get people working together, to get back to valuing people over profits, as opposed to the current mantra, which is completely the opposite.

And again, know, connection. It's all about connection and collaboration, you know, and not at our own little silos like we talked about, but all caregivers,

I couldn't agree more. I was struck, Todd, by your movie trailer and hopefully more people will see it after our discussion today. But terms like it's a war zone down there. We don't know if this system is going to be around in five years, the way things are going. And medicine killed my husband. Medicine killed my partner in life.

There's some serious things going on here which I don't think...

everybody truly understands. And can you elaborate a little bit on this messaging and like where are we at here? Is there a clock ticking that no one hears but you and others hear it and you're trying to sort of get people to wake up and hear the clock ticks?

Speaker 1 (50:37.656)
That's a good way to describe it. I do think there's a clock ticking. And in some instances or areas of the world, US and beyond, healthcare delivery, as we know, it's on the verge of implosion or absent, completely absent. You know, in the stories I've heard of people being inadvertently killed or...

actively killed, frankly, for one reason or another are not just a couple. mean, one story that comes to mind about... It's from Linda Pino. Linda Pino is a physician who was a whistleblower back in the mid-80s, I think it was, on Humana. And she tells the story where she was in a position to do prior authorizations or approvals for procedures. And a young man, and I could believe he was in his 20s,

I think had a viral cardiomyopathy from what I understood and needed a heart transplant or he was going to die. And the heart came available. They had the guy in the hospital. They were ready to do the procedure, but the hospital was out of network. And so there was going to be about a half a million dollar price tag that the insurance company didn't want to absorb. And so they pressured her into denying that procedure. That decision killed that man.

No doubt about it. Had he gotten that far, maybe he would have lived five years, 10 years, 20, who knows? As it stands, he died, I think it was two or three months later. That's disgusting. And this kind of stuff's happening all the time in the United States. You know, look at the disparities and like maternal mortality rates. And I'm not a statistician or an epidemiologist, but our numbers suck.

in some places in the United States. Like, it's almost like there's no obstetric care. Or what people are getting are so substandard that we are so far outliers with maternal mortality. It's embarrassing for a country who's spending nearly $5 trillion on healthcare delivery. So are we at a point in time where things are self-destructing or already have self-destructed? I think the short answer is yes.

Speaker 1 (52:59.212)
You know, we, people talk about a dumpster fire and I grabbed my coffee cup here so I'll show it up there. I mean, in many instances, this is what's going on. And people are standing there staring at it going, I don't know what to do. Like, it's a mess. Things are on fire. I guess I'll just put my head down and do the best I can. You know, it's sad. And that takes its toll on people.

One point on the map or in the infrastructure of the system can't be the first mover. There needs to be sort of a collective multiple points moving in unison to make sure that progress can be made. But you could have told me 100 examples, but that one example hit the nail on the head.

And maybe because that individual was 20 and had made huge contributions and hadn't realized their full human potential, maybe in some back room some calculations were made and that their ROI wasn't worth it. But that's not what we went into healthcare for.

No, not at all. And you know, the worst part of it for Linda in the story, you can't make this stuff up. The day that she had to make that decision, she was walking out of the office and they were installing a $3.8 million sculpture in the lobby. This organization.

I don't know else you need to say about that example other than it is.

Speaker 1 (54:34.702)
It's appalling that those kinds of things occur. you know, and I don't want to dwell on the negative market. I mean, I think the flip side of this coin is that, you know, we've got all these amazing people and well-educated people and well-positioned people all up and down the cure continuum who want to get involved and are ready to get involved. And the timing to me is like,

Okay, let's go. We got this energy. People have had it. They want to do something. Let's give them a path. And I think that's how I gravitated towards some of the organizations that I'm involved with. And yeah, I'm happy to kind of dive into some of that.

Absolutely. you know, take our collective hand and start walking us down this path and show us what we can do as caregivers, as citizens of the world. And let's start really exploring this with some granularity and let's see where it takes us.

I really hope we have some listeners today who are in training at the junior level because this is for you also. This is not for the mid-career folks who've burned out and are trying to reinvent themselves. No, this message has to start at the grassroots level and at the youngest, foremost youngest individuals training to be the caregivers of tomorrow because they need to be aware of this too.

I was amazed recently, you know, I've had the good fortune of being a program director in postgraduate training and I've done so many interviews over the years, but I'm always amazed at how, while there may be a portion of individuals who feel kind of burnt out in training, people do amass quite a good set of coping skills by the time they finish postgraduate training in the medical specialties and

Speaker 2 (56:40.078)
happy to talk about it, but yet then you hear the statistics of what happens afterwards. And it almost sounds there too, like, you know, it's easy to wellness skills in a silo. But when you go into the real world and they get eroded because you're thrown a complete curveball, that's not a good preparation for the next generation either. So

Let's explore a little bit further perhaps talking about Medicine Forward and where you see the big wins there with this movement and then of course the messaging and the awareness that your movie in progress is meant to achieve.

So Medicine Forward, you know, and again, I say this, Mark, and I'm obviously biased, but Medicine Forward was an organization that as soon as I got connected with it, there was something different about it. There was something that was special. And I don't know if that's because I became good friends with Gabe Charbonneau, who was one of the co-founders, but it would just, and I talked to all, I mean, I can't even tell you how many dozens of different organizations I talked to.

But I landed back with medicine forward, think, for a host of reasons. Originally, medicine forward, to give you some backstory, was intended to be a way for physicians to organize differently. Think about maybe, like, physicians organizing in a parallel universe other than the AMA or the American Medical Association. That's kind of the original idea. You probably were getting physicians to do anything together at times as, herding cats. Everyone has their own idea and running in different directions and...

and so on and so forth, all this energy and brilliance, so to have you, but to get it to be a cohesive unit can be problematic. So medicine forward evolved over time and became much more open to really anybody that wanted to be a positive change agent, particularly within the healthcare arena, right? Nurse, physician, APP, administrator, patient, caregiver of some capacity, anybody.

Speaker 2 (58:45.858)
What's an APP, sorry?

I'm sorry, advanced practice provider. So there's practitioner or a physician's assistant. Sorry, sometimes I'm throwing out acronyms. It's a border between the two. And so it was kind of magical as we went through the process of thinking about the organization and really what is the true north of the organization. And so I ended up posting a retreat.

Sorry, mean, giving systems... No problem.

Speaker 1 (59:17.134)
for seven of the leaders. And we really dove into the mission and the vision of the organization. And ultimately, we landed on the mission statement of catalyzing positive change so the patient-physician relationship can flourish. Now, having said that, we are fully aware that there is an entire ecosystem around the patient-physician relationship, of which

A whole host of caregivers are involved in that, right? But if we listed everyone under the sun, our mission statement would be 10,000 words and then we would lose everybody. As it stands, I think we've kind of landed in a good spot. And we've also developed really a decentralized approach to organizing, which there's some risk related to that. It is the opposite of this hierarchical, bureaucratic decision-making process.

And there's going to be some failures, right? And you have to be okay with that. But the failures aren't worth killing someone. The failures are the commas in the wrong spot on the newsletter. Okay, we can get over that. By doing that, it has allowed several individuals to really find their true North Star, if you will. They joined the group looking for community, met other individuals. I can think of one right off the top of my head, Jeff Cohn. He's a...

retired hematologist oncologist in the Philly area. Jeff was part of the leadership group for a long time and is a big fan of coaching and a positive intelligence and being involved in Medicine Board. He made some other connections with some individuals and they're now moving on and creating a group around this kind of work. Or some of the work that Denise Wiseman and Don Ellison are doing and Paul Burens with the Healthcare Reinvention Collaborative, which is looking to

be a component of an impact network or a hub for an impact network. All these individuals were attached to medicine forward. They came for community, they came for clea, collegiality, healing, what have you. And through the process of being involved, many of them found their jam, which I think is, it's, it's a little sad when you see people kind of come and then go, but at the same time, it's like, holy smokes, they're doing these amazing things now.

Speaker 1 (01:01:41.804)
And at one point they were part of Medicine Forward. So it's kind of become this repository for people to talk and gather and find where they want to go. We've got a program going on right now called the Rising Star Program, which Dr. Christopher Berringer is the leader on. He's a family physician in the Midwest. And basically it allows people who are interested in doing writing, podcasting, or event gathering

to get some framework, to get some mentoring, to get some coaching, and go forward with it. And it's really targeting those younger individuals who have a voice and want to learn how to utilize it and can get some coaching from others along the way. And so yeah, it's been such a blessing to be a part of the group and to meet all these people. And it's five bucks to join. We have a monthly newsletter. There's really no expectations. You can be involved or.

as passive as you want to be, but it's definitely a great landing spot for people who are looking for members that they're aligned with or part of their tribe or whatever, you know, their team or whatever word you want to use.

can imagine that that sort of experience as people branch out and champion their own niches helps always remind them of where their roots are and the organization that sort of propelled them or helped them propel or find the connection and energy to be able to then sort of launch. are the biggest wins that medicine forward has achieved so far in terms of sort

enacting change as a unit and promoting change as a unit of thinkers.

Speaker 1 (01:03:28.622)
This question is always a little difficult to give super granular answers to, think, part. But I'm going to give it a go regardless. Right. So because I think it's important. When you're catalyzing things, you are not necessarily the forward-facing component to the project. Or you're not the one getting the accolades.

to whatever metric you're working on. I can think of a couple examples of this. We championed a open space technology event at the Burnout Symposium in New York City in November 2024. There were about, I want to say 40 people in that room. And open space technology is a fascinating way to facilitate conversation. There's some.

I'm not an expert, so I'm probably going to screw some of this up, so forgive me. This is part of the calculated risk of all this stuff. But there's some framing questions, and then you get together with groups. And out of that three-hour event, I know for certain that there were several major events that are, or connections and or collaborations that occurred as a result of it. For example, some of Kim Downey's work with her book was developed there.

A relationship with the Kern National Network was facilitated there. A relationship with the Gold Foundation was facilitated there amongst a whole host of other things that occurred. So it's really hard to quantify. So that's just one example. Another one that's definitely more measurable is the success with the newsletter, the Medicine Forward newsletter, which is on Substack. And I'm not here to try and pitch the newsletter, but by shifting how we are

the cadence of it, the themes of it, how we are capturing content. Our subscribership is up like 10 year to date, I want to say 35 % or something like that. And it's a beautiful way to celebrate other people's work. You know, if we just basically an open invitation for individuals, for example, this month, the theme is justice and healthcare. And so I reached out to a couple of friends who I knew that that was their, you know, wheelhouse or whatever.

Speaker 1 (01:05:49.92)
And one of the people that wrote an article was Rick Mountcastle. For those of you that don't know who Rick is, Rick was one of the lawyers highlighted in the documentary Dopesick, who went after Purdue Pharmaceuticals for the Oxycontin mask that currently is, we're still unraveling and dealing with here, not only in the U.S., but around the world. Rick wrote an article about justice in healthcare. mean, what amazing is that, that

Through Medicine Forward, we got somebody like a Rick Mountcastle writing an article in the newsletter. that's just some of the stuff. mean, the biggest project that's going on that's heavily Medicine Forward involved is Sucking Up Buttercup. The two physician executive producers are also on the board of Medicine Forward. So we're not out there shouting all this, kind of back in the shadows working on this project, but...

Medicine Forward is heavily involved in the documentary production, up to and including several other key caregivers, clinicians, et cetera, who are supporting financially or through connections. You know, I think about, I know I'm rambling a little bit, but I'm trying to give you a ton of sort of different granular answers.

No, this is perfect. I think it attests to the fact that it's not a one size fits all. It's not a rubber stamp sort of this is it. It's about creating a space where innovative thinking and collective support can occur and feedback can be safe and you can take things places. that's what I've heard through what you've been telling me. that at the same time, there's that sense that there's a safe spot where there's a shared.

value system that you can then move forward. I see how naturally this movie has emerged from that space. I look forward to hearing about it. And I got to be honest with you, I saw that trailer and I said, got to, I got to reach out to Dr. Todd and see if he'll come and speak to I was so taken aback by that trailer.

Speaker 2 (01:08:01.656)
felt a little shaky inside and as someone who's committed a career to.

caregiving as a professional and thinks about caregiving in so many different domains and spaces. That really hit me hard. And what struck me also was that it was unifying and that it wasn't just a siloed group of victims. It was about the collective and what the collective's going through using examples. we know that the message in that

trailer, also the message in the movie to come is going to be very universal and very much needed to be heard. So walk us through a little bit about the birth of that and where it's headed. And I know you're well on the way to meeting the needs for ongoing production and we're happy to be contributors as well to supporting that and funding it. So

Where is it going?

So where is it going is I think I'll share a little bit in terms of the story arc, you will. Because the sizzle reel, you know, when you start a project, who do you reach out to first? You reach out to your inner circle, right? So as two physicians leading this, who do you reach out to? A bunch of other physicians. It's kind of a no-brainer. the current sizzle reel obviously is position heavy and we're eternally grateful for Wendy Dean to be...

Speaker 1 (01:09:38.946)
that really that first big name that said, yep, hey, I'll be interviewed. Let's see how it goes. And Wendy's been supportive along the way. But the voices that will be represented in this project go far beyond physicians, as I mentioned. We're envisioning, and again, making a documentary is like building an airplane as you're flying it. Possibly in this airplane, maybe you are doing the appendectomy in the back, I suppose, as a callback to being a flight surgeon.

The reality is there'll be a physician story arc, there'll be a nursing story arc, there'll be a patient story arc woven throughout this. And so you'll get the voice of a multitude of stakeholders, but not just talking about all the problems. There's so many problems, the documentary would take weeks to go through everything, So we're gonna highlight a handful, but really it's going to morph through storytelling to

ways forward and how can people participate and how can we activate those voices of people that want to do something. And you know, I talked about the two evergreen calls to action being unlearning word helplessness and trying to accelerate an impact network. But there's another way you could think about this just if you're sitting back going, okay, I'm I'm pick up

caregiving profession and I'm one person and I'm feeling stuck and what can I do? I often talk about time, talent, or treasure. And those three buckets of being able to give back, okay? And not everybody has the talent. Not everybody's gonna write a book or make a documentary or host a podcast or do all these other things that are incredible. Not everybody has that confidence, right? You know, maybe you don't have the time for that, right?

But I'm pretty certain just about everybody could skip a cup of coffee and donate to their favorite nonprofit that's trying to move the needle. Five bucks times pick a number starts to add up and makes a difference and helps support those that are really trying to be at the tip of the spear to make the difference. So there's all kinds of ways that people can participate and get involved in. And ultimately, that's a big part of what we're trying to do.

Speaker 1 (01:12:04.718)
with these projects not only in Medicine Forward but with the documentary as well.

You know, watching that trailer, I think I could pretty much recapitulate sort of my head just sort of moving like that and my mouth going. What if nothing changes? Like, where are we headed here?

Speaker 2 (01:12:30.806)
It sounds to me like we have a very good taste of, like I feel a strong motive force here, but we've all recognized historically that the factors or the forces that we're always working against when it comes to dynamic healthcare systems across the world and they all have their own flavor. The message is striking from the trailer and, but I can't help but think if the...

know, siloed forces that have maintained the status quo for all these years are still at play and we can't achieve what we want to through this movie and through this raised awareness. Like, what if nothing changes and who's at risk? Like, the stakes now are higher than ever and the news wires are just full of statistics about...

Caregiver suicides, senescence and people quitting the profession and completely revamping after dedicating years of training to develop a skill set which is not replaceable overnight. Shortages in professional caregivers, shortages in caregivers in the home space who are professional, inability to cope of family caregivers with the demands and increasing complexity of looking after

ailing loved ones whose medical care is more complex than ever. So many things are at stake, but where are the biggest risks and who's at biggest risk if nothing changes and we're just faced with the status quo? I'd love to know your thoughts. You're so privy to the inner circle thinking and making this movie and the reactions to it and what you're hearing. mean, people need to hear.

What you've got, what's going through your head as being right in there, know, witnessing these interviews and this data coming about.

Speaker 1 (01:14:27.694)
First and foremost, Mark, I think you said it very well and I'm almost debating what to say here. I don't want to unwind what you just said. was so good. I think simply put, people will die. Multiple people we interviewed.

Echo that sentiment over and over and over again. If we don't get our crap together and start taking care of other human beings like human beings and focused on the almighty dollar or whatever currency you have, people die. And people die for crappy reasons. And it's inexcusable. you know, if you think of one death that didn't need to occur is one death too many, but this is hundreds of thousands of deaths that are occurring as a result of how we've structured our ability to deliver care.

if that doesn't hit you hard, think about a parent and they've got a health issue, whether it's a cardiac arrest, whether it's a stroke, whether it's can't related to cancer or diabetes, and they can't get the care. can't get navigated. They can't get funded. Pick a reason. And they die as a result of that. Are you okay with that?

If it's your loved one, I'm not. Not at all. I don't think anybody should be. And I think that's the big risk here. it's, it's, unfortunately, it's playing out all over the place. And the people at highest risk are those that are marginalized. Whether it's funding, whether it's ethnicity, whether it's background, you know, whatever health disparity you want to pick.

the people who are marginalized are at the highest risk of suffering that fate.

Speaker 1 (01:16:25.42)
You know, it makes me sad when I think about that, that we are choosing profits over people regularly. And I don't think many are doing it intentionally per se, but it's so interwoven into our systems. Yeah, that it's just incredibly problematic.

So with this momentum that you've got and you're developing, which I think is palpable and I...

I can't speak enough about it. What resistance have you met so far, if any? Are the warning signs out there already? is it more like, well, just wait till they see this. This will maybe settle the argument. But is the resistance emerging or like the elbow nudges sort of like, yep, that's kind of as we thought.

The short answer is yes. And I think the resistance is occurring maybe in some expected, maybe not this early places. know, like people are afraid to rock the apple cart because of how it might affect their little sphere. We're seeing that start to play out. You know, I'm not going to name names or name organizations or institutions or whatever, but people are afraid

to challenge the status quo and what might that mean? And then what might that mean for an individual? What might that mean for the collective? That's been fascinating to see like some organizations that I thought this was a no brainer that they would want to get behind what we're doing have expressed fear and reservation because how it might affect their progress. The reality of it is though, is we're trying to, there's a book called the Spider and the Starfish that Jeff Cohen actually recommended to me, which talks about

Speaker 1 (01:18:19.352)
decentralized organizations and that was some of the brainchild for medicine forward and so on and so forth. And the analogy is if you've got a spider and you cut off its head, that's it. It's not, if have a starfish and you cut off its leg, it's gonna grow another one. And that's how movements start to become very successful and powerful. And that's part of what we're trying to propel with this. God forbid, say someone comes after me, this project's gonna go on.

The way it's set up, the Evergreen calls to action, you know, don't need Todd at this point. The cat's out of the bag. And then that's what we want people to have is to get beyond those insular fears and realize that there are support groups out there that you are not alone. But back to your question, and resistance is probably going to come up more and more and more. I have a feeling we'll get some resistance from some.

institutional players, I'm not going to name names, whether it's Big Pharma, whether it's insurance companies or that kind of thing. We're not really targeting specific entities intentionally, but to make change, you're going to piss some people off. And frankly, that needs to happen.

You know, there's obliterating and then there's reining in. you know, part of progress is just reining in a little bit and realigning.

different individuals or organizations with the values that sort of brought us to healthcare to begin with. And it was probably a mission statement and a value statement in somewhere buried in the originator documents, and it wasn't all shareholder value. So it would be...

Speaker 2 (01:20:09.762)
The hope would be that reining in a little bit by raising awareness, which you do so strikingly well, whereby, you know, that might be the real catalyst for sure.

You know, hearing your story a little bit and you're embarking on this new chapter of your life in organizational involvement and with this movie and an amazing path that doesn't really have any footprints to follow in ahead of you in all of this. How are you looking after yourself now as things are mounting up and revving out differently than maybe how you did 10 or 15 years ago?

What messaging might you have for some of the younger crew who are listening?

Boy, that's a tough question having come from the generation of put the patient first and put everything else first and somewhere down at the bottom is yourself. And you know, that's how I was trained where Maslow's hierarchy of needs be damned. So am I perfect with it? No, I'd be lying to you if I said I was.

I the club, mean, caregiving and sacrificing me has been my currency for as far back as I can remember. a lot of introspection is actually, mean, it's kind of how I almost was in high school when I was a great listener. And that's because I just put that other person in front of me ahead of everything else. And I think it just sort of shaped how I took on and the habits that I sort of developed in life and, you know, whether

Speaker 2 (01:21:53.09)
no matter what domain it was, it was okay if I came in last as a priority. And so I can see where you're coming from. And it's a very challenging sort of mold to just sort of fracture and break out of and then try to reform new habits. As you know, new habits take time and new experiences to reinforce them. So, unless I keep rambling, what you were getting at the point that, you know,

It goes way back, but now here you are now. Where do you see it going now, having broken perhaps a little bit from that mold of hair giver last on the list?

Where is it going personally is what you're asking. Okay, that's I just want to make sure on the same page. know, having been trained in an era where trauma-informed care wasn't at the forefront, and now that I'm truly appreciating the magnitude of that, I realize for much of my life I've been running from things that I didn't want to remember or deal with. You you look at my CV mark and it's...

It's like one accolade after another after another. And many of us are like that. And then the question is why? What happened that we're always striving for that next set of things that gives us external validation? And I think there's some important lessons there to be had for the younger generation so that they don't repeat the mistakes of our generation, if you will. I think setting boundaries is critical.

I think learning to say no is okay. I think taking care of yourself is of utmost importance. If you're not at your best as a clinician, regardless of your role,

Speaker 1 (01:23:45.448)
What kind of care are you giving to the person you're trying to help? You know, if a patient comes in and they've got a 50-50 chance that their physician they're seeing is burned out, that's not really good. You know, what kind of care are you getting from that? So I think you've got to, self-care is absolutely critical. And I think, you know, there are mentors out there. There are resources out there. And you don't have to be alone, whether it's medicine for, whether it's physicians anonymous.

I could start naming all sorts of different organizations that you could join as a resource depending on where you're at and what your struggles might be. And maybe the ultimate thing is you're really not alone. You're not. There are so many people out there who are either struggling with similar things or what have you. And it takes courage to ask for help. And so I guess maybe what I'm saying in a long-winded old man

gray-haired on-the-chin fashion is that it's okay to not be okay. And as soon as you recognize that, that's the first step in healing or getting to a better place. you know, much like you, it's a lifelong process. It's a roller coaster. It's not a linear path. You you look at the trauma recovery things and there's loops. You know, you make two steps forward and you have a setback.

It's how do you take that? How do you frame that? How do you learn from it? And my hope with like Medicine Forward and my journey in the book and the documentary is to take some of the painful lessons that I've gone through, offer them up for other people to say, you know what, maybe I don't want to go down this path and I need to deviate or push back on an administration that's trying to do something that's not right. So yeah, there's all kinds of opportunity there. I guess that's my personal

rambling journey of where I'm at now. But I wouldn't change it for the world either, so I'll leave it at that.

Speaker 2 (01:25:48.814)
Sure. mean, I think.

If you pick caregiving as a profession, it's not easy. No one said it would be, and it doesn't mean you're an automatic victim for having made that choice. And I think shared victimhood is the wrong path to think of this whole process. But you really hit the nail on the head where you say, don't do this alone. Whether you're allied health personnel, whether you're physician,

whether you're a caregiver at home, encountering some serious trauma watching your loved one, your child, your partner getting sicker and sicker, et cetera, you need to find that sort of empowerment to say, I'm not going to go through this alone. You can adopt various habits, et cetera. And there's a whole science behind that to sort of work on yourself and build reinforcing habits. But doing it in a silo and doing it alone is probably

know, forsakes.

that most important factor which we all crave, which is connection. And that's probably going to keep us going well into our 80s and 90s if we have connections. If we don't, we're in big trouble. So it's that connection together and in seeking help and acceptance that this is okay. And it'll strengthen numbers as we try to move forward and build our tool set to stay resilient. Because it is a tough choice and it's as rewarding as it is. It's not easy.

Speaker 2 (01:27:23.662)
But there's a lot of philosophers who said don't do easy things, right? So I hear you exactly. And just not going through it alone and thinking that you need to keep it all inside. I think too, the importance and the emergence of debriefing sessions now in ICUs and in emergency rooms when things...

go awry and people witness difficult situations that we all gotta sit back afterwards and have a cup of coffee and talk about it and create a safe space if someone needs to cry or vent or whatever. that's part of the oil that keeps the system going as well. And we can't, we can't disacknowledge that place and sucking it up and moving on and the old traditional sense of

is really doesn't have its place anymore if we want to keep a healthy cadre of caregivers across the spectrum. If you had to pick something to fix right away, like thinking about, you know, entry level changes, would it be med school or nursing or social work? It doesn't matter which, but is it, is it at the learning phase early on where we can have the

the biggest impact for the future? do you think there are certain things right now that need to change or else? And I mean, I may not be asking you, I may be asking that like from your collective experience from the people you've been working with. Do we, does most of the learning about the problems of today need to be imparted to the next generation so they're best prepared to be the motivators of change or be best equipped to walk strongly

through it when they emerge from training and enter the real world? are there certain things that we need to fix today and if not, we're in big trouble?

Speaker 1 (01:29:22.702)
This is phenomenal question, Mark, and I think you can go in a whole boatload of directions. When it comes to, and I'm going to say medical education again, I'm a physician, so kind of default to what you know, but this applies to nursing, this applies to every caregiver up and down the line. think there are some, and it's being worked on, I think there are some fundamental flaws.

in how we are training people. You we talked about trauma and processing. I think that's one thing. I think the culture of fear and shaming and blaming and scapegoating needs to go away. You know, we talk about a just culture. I don't know if you're familiar with a just culture, that culture where it's okay to bring up things that you're concerned about. You're not going to be vilified for bringing up

something that might be a black eye on the institution and all these other things. That is the exception rather than the norm in the United States without a doubt. boy. The things that go on, like I'm not an expert on Shampere review, but Shampere review is just a perfect example of that where people are literally getting things put in their file that are completely made up to get rid of

Still.

Speaker 1 (01:30:47.106)
that individual from an institution, just often destroying their career in the process. It's appalling. The things that go on behind the scenes are disgusting on many levels. And so these dark sides of medicine, if you will, nursing, eating their own, the culture of nursing, eating their young, these things need to go away, like now.

Because we already have a mass exodus of amazing people who are just fed up with being treated like garbage and or taking the worst route, which is dying by suicide. These are fixable problems. These are cultural problems. But these are intergenerational traumas that have been passed on from the generation before me and the generation before that and the generation before that that need to be undone. There's no place for some of these things.

the people that are trying to care for other human beings.

So how do we combat the cynicism in all of this and the feeling of disempowerment that listeners today may feel in terms of, this sounds insurmountable, I'll just head down and put my head down and just keep plowing. It doesn't sound like an acceptable alternative anymore.

Yeah, think, and that's where I think one of the, I'll go back to the documentary, you know, with Suck it Up Buttercup. I think one of the simple evergreen calls to action is unlearning learned helplessness.

Speaker 1 (01:32:24.21)
I can't state how powerful I believe that is. Your voice does matter. Your actions do matter. And if you scale those things, they will be difficult to ignore. And the overwhelming cynicism can then be morphed into overwhelming optimism and seeing the path forward to a better place. And I'll give you an example of this, a personal example, because stories...

are often what people just cling onto and remember and what have you. We had a quality metric. So a component of our pay was related to medication reconciliation. For those not familiar, medication reconciliation is a critical piece of delivering good quality health care, making sure that the caregivers know exactly what the patients are taking for medication and everyone's on the same page. Absolutely needed.

critical, important, whatever adjective you want to use. Anyways, the metric involved was a survey as to how well the patients thought the medication reconciliation went. Okay, certainly that's fine. But then that was then tied to compensation. So we are tying compensation to a survey when oftentimes the patient has absolutely no idea what medication they're taking.

or they're taking the blue pill or the purple pill or the orange or circle one or whatever, and then tying this to someone else's pay, this was in my mind a dangerous slippery slope to very bad behaviors that I won't get into. As a result of this, I said, I'm not going to participate in this. I think you are going to perpetuate some very bad behaviors in clinicians. I think you're going to perpetuate some very bad behaviors in patients, and I am not going to do it.

And I wrote an email to that specific insurer saying just that. I had no idea that there were like hundreds of my colleagues doing the exact same email at the exact same time to the point which that initiative was taken off the books.

Speaker 1 (01:34:33.55)
Had all of a sudden nothing, that initiative would have went forward. But as it stood, we all took a mini stand on one minor thing and it made a difference. And that's just a very simple example of the power of numbers. Imagine scaling that to all kinds of other things that are out there. Maybe just one other example of something in the works. I've got a friend called Matthew, or not called, his name is Matthew Zachary. And Matthew is a celebrity.

cancer survivor, patient advocate, who has a very amazing project called We the Patients in the Works. And ultimately, they are trying to, well, I don't want to usurp Matthew's work, but they're trying to activate cancer survivors and their families to move the needle in a really an amazing positive direction. That's the power of numbers. That is on learning learned helplessness.

And in the setting of chronic injury or chronic pain or chronic trauma from a system that seems immovable, learned helplessness can explode into other areas and that can lead to catastrophizing and alienation of your partner or your colleagues or yourself. And it just snowballs into so many potential things. And it's so interesting that you identify that.

helplessness being something that's so within target to reverse. We've spoken a lot today about so many elements of this, where we find ourselves now and

In the trenches, we're trying to overcome witnessing colleagues suffering, patients suffering, allied health personnel suffering. And then I can't help but think of the caregivers who might be coming in with their loved one who's a sick patient who are barely, barely hanging on at home being able to manage.

Speaker 2 (01:36:36.492)
to be able to manage not only their loved one or the person they're caring for, but even managing themselves. I caregiver burnout at home is starting to reach epidemic proportions as well because the demand is incessant. What can caregivers at home learn from this movement? And how can we

as individuals who share in the values of caring for patients offer what we're learning to caregivers at home to support them, but also support their movements and what they're trying to achieve. Because I think we're seeing a rise of awareness that, know, caregiving at home is providing a lot of indirect cost savings to the system, yet caregivers at home are just burning out.

because it's so difficult. What can they learn from us? And what can they learn from you and your experiences specifically so we can collectively empower each other? Because I don't, I think we're all part of a continuum. I don't think we're separate at all. I think we're actually all part of one.

And I think the root cause contributing to whether it's burnout in clinicians or burnout in caregivers at home, it all comes back to and how greed has pushed the care into those that aren't getting compensated and family members and all the things that you just alluded to. I think some of the self-care things that we're advocating for for clinicians are totally applicable to people at home. know, take advantage of breastfed care.

is just one example of, take a break, let somebody else do the worthwhile, even if it's just a couple hours a day, make sure that you're getting something in your day that you enjoy so that you're not, quote unquote, getting burned out. I think that's just one example. I think perhaps related to that, if you will, is the ability to search out the resources that are available that because you don't know what you don't know.

Speaker 1 (01:38:48.462)
And information is just overwhelming and there's false information and AI hallucinates and all these other things. I think there's some ways to navigate that. Not everybody has a clinician or a physician or a nurse in their family that can help them do these things. But there are tools that if utilized correctly can help you get to a better place. Some of that's related to networking. Some of that's related to research. I think a simple tool that is

can be quite effective if done and utilized appropriately as a generative AI. And I'll throw chat GPT out there because that's just the one that everybody thinks of. If you ask the question with enough granular detail and to include resources, you often can get some very good information from there. But there's another generative AI tool that's out there that I don't think the vast majority of people are aware of is called open evidence AI.

And OpenEvidence searches medical journals for specific queries and then spits out the references. It's a fascinating tool. So those are just a couple ways of, I guess, thinking outside of the box, how you can navigate not respite care, but caregiving at home. Just a couple random thoughts that I have for sure.

Absolutely. I mean, that's, as you've said a couple of times, we've encountered so many interesting ideas that could form the basis of a whole separate podcast episode in the future. AI is certainly making headlines in terms of its development specifically in the home caregiver domain, where certain tools are now being looked at to facilitate.

You know, even if it means, if we're gonna talk about finding some time for self-respiratory self-care, but if you can have an AI tool at home that can make sure that someone's being kept on and they get their, an eye on and they get their medications taken on time, if they're having early cognitive decline, something that as a caregiver gives you some space to breathe a little bit so you can engage in some self-care, that's a huge win. And I'm certainly very interested to see where and how, you know,

Speaker 2 (01:41:03.072)
AI could be applied in the elite setting or it can be applied for the masses and where small wins can be achieved across so many individuals in so many spaces. And if those tools are refined, it could certainly be a huge win for the caregivers at home. And there's been quite a buzz on the news wires about different.

thoughts and devices and platforms which are being tested and are raising eyebrows and potentially having an impact on the home caregiving scene. And I look forward to seeing more about that. You know, my personal belief is that there's some amazing tools that can change the lives of caregivers everywhere if we know how to use them correctly and if we understand their limits and their limitations in performance.

And time will tell, I don't think caregivers everywhere are going to be replaced overnight, but we could certainly learn about the tools that can make the delivery of care better for the patient and for the caregiver experience altogether.

And you make, you me come up with another thought, Mark, as you were talking, and maybe this is just a simple life hack. I don't remember who told me this along the way, but somebody in my career suggested you attract more bees with honey. You know, and it really, to me, the moral of that is, you know, be kind and nice to other people. You know, when you're calling your primary care physician's office, they're struggling. It's chaotic. They're overwhelmed.

Ask them how they're doing. Send them a thank you card. Be kind. I almost guarantee you are going to get an extra level of service when you approach somebody with that attitude versus chewing their hat off because a mistake was made. know, kindness cures many, many things during those interactions. And frankly, in many cases, probably would provide more resources just on a whole

Speaker 1 (01:43:11.81)
Host of levels, mean, whether it's another five minutes with your clinician or a few extra minutes on the phone, those moments can be life altering. So.

the power of kindness has been identified in so many areas as being an incredibly easy but powerful tool in itself. And depending again, every area has its sort of unique flavor. You might be the intermediary between the decision makers at the insurance company and the patient sitting in front of you, or in other parts of the world.

the interface between government programs and the patient sitting in front of you or the wait list and patients sitting in front of you. And very often we find ourselves a little bit disempowered as being able to move the needle a whole lot beyond wearing what becomes necessary in certain instances as an urgent advocacy hat. we're recognizing and we've certainly seen it here that there's a shortage of family physicians and primary caregivers emerging on the

in the Canadian scene and we're hoping that there'll be some important solutions made. And I look forward to in a couple of weeks interviewing a mainstream thinker who is challenging us to think a little bit about, well, maybe what we need to be producing is what society needs in terms of caregivers. And on that note, we probably need to...

also be producing the most resilient, adaptable caregivers as well who know how to take care of themselves. I think maybe we wrap it up on that positive note and the power of kindness. It's been an amazing discussion with you today. I hear you. We've tackled some really difficult aspects, but at the same time, I think we need to frame this with the power of hope and the power of change and the power of new

Speaker 2 (01:45:20.334)
collective strength that your projects certainly embody and make sure that, and this will be an important resonant theme to a lot of our episodes as we come to a close, is think about the next generation, the caregivers to come. It's so important that they learn from us and that we take the time to speak with them, to share with them, and that can only occur in a

community of sharing and with a sharing mindset. And I think a sharing mindset is as important as a growth mindset when it comes to making sure that the next generation of caregivers are as best equipped as possible to carry on the mission.

I'd like to thank you, Todd, for joining us today. This has been just a wonderful chance to meet but also explore. And I look forward to having you visit us again someday and give us an update on amazing progress and look forward to seeing the full movie eventually. And I too have signed up for the Medicine Forward newsletter and look forward to starting to receive those.

share in our sort of collective wisdom moving forward.

If you have in me an open invitation, if you want to include a piece to the newsletter and maybe I'll just leave with this last little sentence I met with a colleague, Diana Landonio, a zoologist out on the West Coast. And for a while I was hosting a podcast and had her on the show. the title of the episode was, Love is Always the Hints.

Speaker 1 (01:47:12.8)
I'll leave it there. Thank you for having me.

Godspeed. Before we wrap up, I wanted to remind you of something important. The conversations you hear on this podcast are here to inform, to support, to spark reflection. We're not a substitute for professional medical advice, care, therapy, or crisis services. Listening to this podcast does not create a doctor-patient or caregiver-client relationship between us. If you're facing a medical concern, health challenge, a mental health challenge, or a caregiving situation that needs guidance, I encourage you to reach out to a qualified professional who knows your story. If you're ever in crisis,

Please don't wait. Call your local emergency number or recognize Crisis Hotline right away. You deserve real time help and support. The views you hear on this show, whether from me or my guests, are our own. They don't necessarily reflect any organizations we work with, are part of, or have worked with or been part of in the past. This podcast is an independent production. It's not tied to any hospital, university, or healthcare system. Thank you for being here, for listening, and most of all, for taking the time to care for yourself while you continue to care for others. I look forward to hearing from you.