Well, hi, everyone. I'm Daniel Williams, senior editor at MGMA and host of the MGMA Podcast Network. We're back with another MGMA Insights podcast today, and I'm happy to say we have an actual doctor here today. We get a couple of episodes a year where we do have a doctor. Today we're joined by

Dr. Brian Gietzen. He is medical director at Legacy Medical Group, and we're going be talking about approach to medicine and a practice that he calls benefits based medicine. So Doctor. Gietzen, first of all, I just want to welcome you to the show.

Thank you. I did not realize that I was a rarity, but glad to participate for sure.

Yeah, we do definitely have some doctors on the show, but I would say primarily the majority are practice administrators in one function or another. But we do definitely have some doctors on as well. So let's just start. Love asking this question. You've made a commitment in your life to providing healthcare for people.

What sparked you? Did you know when you were a kid? Was it somewhere in your schooling? When did you make that shift in the mindset to go, you know, I wanna be a doctor?

You know, I come from a medical family, so I that certainly pointed me in that direction. I I would say in college, though, my my focus was on anything but. And it wasn't until about that last semester where I started to reconsider, and I'm I'm absolutely glad that that's the path, that I took. I I see too few people really that are able to be in a position where they're passionate about what they do, and I I really feel lucky every day that that's where I've landed.

Yeah. And when you did go to med school, when did you make, again, an even more focused attention to the type of practice that you'd be involved in, the kind of specialty? When did you make that decision? You

know, it was interesting. As you go through medical school, I'll say various specialties tend to have a certain personality that's attached to it. And for me, I I just realized I was connected to internal medicine Mhmm. As a pathway as as I looked around. So it was sometime within my third or fourth year that, I decided that that was the path I was going to take.

Alright. Well, tell us a little bit about Legacy then. What's the size and scope of the practice? How would you describe it to someone?

Sure. Well, I I would say we are we are a unique practice. We're we're internal medicine based, so that means we largely care for adult patients. I would say the majority of people we see are probably between the age of 40 and 90. K.

And what makes us a bit unique is we in addition to seeing patients in the office, we have a substantial number of geriatric or elderly patients that we see out within senior community. So we're located in Southeast Michigan. We cover the the larger Metro Detroit area as well as, a few counties in in Northern Michigan. So and I would say that that part is is relatively unique, although the approach ends up being largely the same.

Yeah. Mhmm. And then how would you define your role there?

Sure. Well, I'm I'm the medical director, which is a combination of seeing patients directly. I also work with really an amazing team of mid level providers, so I am here to help train, guide, and provide support for them throughout the day as needed.

All right. Now you and I have traded a lot of emails back and forth in preparation for this talk. You shared with me that you really wanted to talk about this model, benefits based medicine. It was a new term for me, might be new to some of our MGMA listeners right now. Let's define it first.

What is benefits based medicine?

Sure. You know, I would presume that it's going to be new because it's an internal term to our practice. So if you were to Google it, I don't know what you would what you would come across. But for us, it's it's really a term to describe how do we meet our patients where they're at. And I think what I mean by that is our goal is to empower our patients and give them information in a way and format that they can be involved in their health care decisions.

And, you know, I think as we talk through in a little bit more detail, it will make more sense both the term and and how it gets used, but that's the primary primary goal.

Okay. So you shared with me some information about the practice, and you talk about guideline based care as the default framework for lots of organizations. But you also brought up the idea that there might be some limits to that. Talk about that, the limitations around it, and how you view it.

So, yeah, so so much of how medicine gets practiced in our current environment is driven through guidelines.

Now Okay.

I always say it's a wonderful place to start because it really does help us as physicians develop a direction. But I find too often, it seems to be where care starts and ends. And I would say the problem I would describe is that by nature, guidelines are a one size fits all approach to care. And and I've yet to to find a scenario in my life where a one size fits all approach

Right.

Fits all people. So, it's a great place to start. But if you finish there, you're you're really, forcing people down pathways that may not be where they really would like to go.

Mhmm. Now something you shared with me was your approach centers on a key question. That key question is how well does it work? Let's talk about that. How did you land on that question, and then how does it shape the direction and the patient interaction you have?

Absolutely. So, you know, I think I started my practice with a strong foundation of curiosity. So it really required me to try to understand what I was telling people. Probably the best way to answer that question is to understand how we answer that question. So when we're trying to figure out if we're gonna provide a recommendation, the first question we have is if we're going to recommend it, is how well does it work?

And I would say, for our perspective, there are really three questions we ask. So the first thing we do is we go and look at clinical trials. That's an incredibly important place to start. When we go there, we ask the question, what is it that they're saying is going to be improving? And I think as we go through a couple examples, it will make more sense.

The second question we ask is, well, who were they studying? So, again, we see a lot of elderly patients. If they were studying people who were 30 or 40, maybe these results don't apply. And then the third question we ask is, well, how big was the benefit? And when we put all of that together, we're actually able to have a very meaningful discussion with people that gets them as close to my knowledge as possible and really does allow them to become active in the decisions in their care.

Okay. One of the things you shared with me through email is that too often that question goes unasked. Why is that?

You know, that is one of my great mysteries as to in medicine, how we miss this point because it seems to me to be such a obvious question and, how we have often sidestepped it. You know, just as I see patients who join our practice or in the world where I seek care myself, it's it's it's been one of my great mysteries. I don't know if I have an answer.

To

why that doesn't get asked

Yeah.

And or answered because the answers are out there.

Right.

Mhmm.

Right. Well, I'm I have faith that you're gonna find it. You're gonna keep asking those questions. You brought up something at the beginning that I think is integral to what is Legacy's mission, and that is to really bring in the patient in the decision making process, in the thought process. I hear that, but it could be it could mean different things for different practices.

What does it mean for legacy?

You know, I'll often give a a little analogy, that I think can be helpful. So I like to describe if we were to drop someone off in the middle of the Amazon, the the guideline based approach is this. We'll we'll get them out, but we're gonna tell them exactly where they're going to go, whether they wanna go there or not. The alternative, I think a lot of people will utilize is Google AI, and and I tell people that's kinda like I I dropped you off in the Amazon and I gave you a map. So it's information, but it can mislead you pretty easily.

Mhmm. I would say what our approach is is we're gonna find you. You're gonna tell us where you wanna go, and we're gonna get you through the Amazon into the other side. And that's really what benefits based medicine is intended to achieve and asking that question, how effective is the intervention we're gonna look at going to work? It really helps people get to where they wanna go.

Two of the examples that you shared with me are hypertension and cholesterol treatment. So let's use those as scenarios. We've dropped these patients off in the Amazon. This is their treatment map. This is how we're gonna get them there.

What does that look like?

Sure. So, yeah, in the world of of treatment, I find oftentimes, get a medicine, we're very quick to them to move to the world of medications. And if you recall that very first question we like to ask is what is the benefit that's being defined? And so I think cholesterol could be a really easy one because oftentimes the discussion is considered around this number, I don't like. It's too high.

Okay. We gotta get you to that number. Yeah. And so the treatment goal is simply a new number.

Mhmm.

The question we would ask, and this is a little bit of an oversimplification, would be something like this. How well did we prevent a heart attack? And I think when we're able to answer that question, it gives people a little better perspective of both how well something works, and then we can also compare it to other options. So, one of the biggest concerns in that area I have is someone who comes in, maybe doesn't have the best health habits. We've put them on one of these medications.

Their cholesterol now looks perfect. And if that is what we've identified as the benefit, I think we can very quickly falsely presume what we have achieved.

Wow. I'm still contextualizing that in my brain, so I'm going to keep working that through. Something that I do connect to is something else you shared with me in emails, and that is screenings. See that. I'm of a certain age where I'm told, well, you got to get in there and screen for this this year, and you gotta go screen for that every year, and you've gotta go you know?

And it's like it can be a little fearful. It can be a little confusing. Walk us through what y'all do at Legacy that really can help contextualize all the screenings that are being brought to that aging population that y'all are dealing with.

Yeah. Absolutely. And in fact, we actually see recommendations moving into a younger and younger group. So, yeah, so I'll I'll spend a second in the world of colon cancer screening because that really ends up applying to all of us. And and I find most people sooner than later are recommended that they need to have a colonoscopy.

That's often where, those discussions lie. So what a benefits based approach will I ask is, first of all, what, well, what is our goal? Mhmm. And, generally, I would argue our goal is to prevent someone from dying from colon cancer. Yeah.

Because anytime we start moving further away from that, it can sound like we've achieved something.

But Yeah.

If you end up still passing away with colon cancer, the question is, did we really achieve a benefit? Once we've set that as our standard, it's actually fairly straightforward to have a conversation on how well does a colonoscopy work? How well does a stool card work? How does that compare to doing nothing? Because we do have patients that I describe are minimalist, and their preference is to do as little Right.

As possible. And I find in a guideline approach, people are essentially shamed or, you know, otherwise, really try to place in a position where maybe their wishes aren't necessarily at the fore. But when we're able to talk within that context, we're able to give people information so that they can make a decision that's reflective of their interests. Don't know. Does that make sense?

It does. It absolutely does. I will follow-up with it, though. How do you clear clear the air then and have a really impactful conversation with a patient if they're hearing guidelines on screenings here from this news outlet or organization or an ad or from someone and then they come into Legacy and y'all are telling them this. I'm sure you've had this conversation and they said, Well I heard that I should have it here this amount of time or this often.

How do you break through that and really get that buy in from the patient? You want them driving that conversation as well, but you wanna give them your best medical advice as well. You

know, this is typically the approach I will, utilize is I will make for those who are are not sure necessarily what their best option is, I'll do a couple things. I'll give them arguments for and arguments against. We'll also ask them to give us a little insight into how they make decisions. And, really, when we put that information together, we will hopefully give them some information or enough for them to provide some input, but then also give them some direction. So, again, that's the difference of, me just giving a map versus being a tour guide.

We we there are some expertise that we have developed through four years of medical school, three years of residency, and and years in practice. So so it's that combination of understanding how they make decisions, giving them, arguments on both sides of the table, as well as the information that we currently have Okay. To help them get to a point of making a decision that makes the most sense for them.

Okay. The next guideline to talk about, this is one all of our listeners are gonna be familiar with whether they're in the medical world or not, and that's vaccine guidelines. That has been a firestorm over the last at least six years with the start with the pandemic, but even probably even before that. How do you work with your patients, gain their trust, give them your best medical advice to explain to them what's needed, from a vaccine side when they're hearing different information from different places?

Absolutely. You know, I I find a couple things. It is an area where people come in oftentimes with very strong opinions

Right.

To begin with. We also find that the information that's available can be quite confusing. So I I always say my first goal is when I'm having a conversation with patients is they have no idea what my personal beliefs are on vaccinations. If if yeah. And then we it's the same basic approach is we're looking at I'll use one as an example.

So if we're looking at the COVID vaccine, what are the current benefits to be had? And, you know, there was a time where we would see what was a mortality benefit. We would prevent deaths.

Right.

COVID has gotten to a point where, fortunately, it's less dangerous, so we don't see that level of benefit. So then we can start talking about, well, what would be the benefit if you were to have

it? Mhmm.

What's the potential risk?

Right.

And I find that those are often left out of the discussion when people are watching TV or hearing all these things could be very argumentative. What they tend to hear is opinions, not information.

And there are we see it with any sort of like if there is an advertisement on television about particular drug in small print, we'll see side effects can be. I'll tell you my fear factor goes up when I'm reading all of those. I go, holy moly. Those are put in there, as you know, because in the trials there are certain instances where there are side effects, there are things that happen. When you walk someone through something like any of the vaccines that are out there, there can be side effects, there can be challenges.

How do you walk your patients through that and explain to them with your best medical advice what's going on there and what could occur?

Absolutely. So you're looking at a couple bits of information. The context that we can bring is, first of all, how dangerous is that? Okay. That can be hard for nonclinical people to understand.

And then the other bit of information is, well, how often does that happen? If it's 95% of the time, that's very different than if it's one in a 100,000. And, again, this is information that isn't typically made easily available. So it does, even from our perspective, require a little work. Yeah.

But it's really those details that help people understand. Because outside of it, it can be very distressful on both sides because it's really hard to put that information into context. Mhmm. And I think that's the kind of information that does that.

Right. When you get into the elderly population, sometimes there can be other family members perhaps. They drove them there. Maybe they're present. Explain that to us just so we get a better understanding of that.

How does that come into play? Is it strictly the patient's decision? Are there other family members that might be involved in some of the health care decisions that are being made?

Yeah. I think I would answer that there is not a one size fits all. We certainly have patients who are competent and have a very clear sense of direction and goals. But a lot of times, we do find that they have family present because they want their perspective. So it's really the same approach.

It's just having more people involved in the discussion.

Okay. Now we've been talking about benefits based medicine at Legacy and how it's worked there. Is this scalable? We've got people who are listening that are administrators practices and clinicians at other practices. Can they implement this at their practice?

You know, I I think to be honest, Daniel, it's really just a matter of interest. And, really, all it requires is individuals to be comfortable with reviewing clinical trials and asking a simple a couple simple questions. And the information is there. The information is there. So I don't know if I wanna get too clinical in this Right.

Discussion, but there's really three to four questions we ask, and they're the same questions on every clinical study. And soon enough, I I would say in my experience with the team members we have here, within about three to five trials, they're able to answer these questions very confidently. So it's really just a matter of interest, a willingness to look back at the original trials, and ask a couple very clear questions.

Okay. Are you able then to, without getting too clinical here, to just share what those basic questions are just so we're on the same plane here? Yeah.

Yeah. So the first question we'll ask is, what is the benefit they define? So, again, I'll go back to that cholesterol.

That's

right. Were they actually studying reduction in heart attacks, or were they studying how well we could lower the cholesterol? Mhmm. It often seems like those are one and the same, but they really aren't. So we're looking for the closest to the item we're most curious in being able to address.

So we'll first ask, what is it they're trying to study? The second question we'll ask, again, this really isn't too clinical, is who did they study? And so how well did that group match the group I'm seeing? So, again, for the elderly population, a lot of times it's younger people.

Yeah.

For our younger people, a lot of times the people that are studied are sicker. So you really wanna make sure, can I apply this to someone that's healthy? And then the third question is how large was the benefit? So that would be the nonclinical way of describing. Once you know those three bits of information, the power to have a discussion with the person in front of you that isn't just giving them recommendations increases, dramatically.

Okay. For our last question, you have touched on this, but I want to reiterate it because it's important for practices interested in adopting this approach. Where do you suggest they start? What's that starting point? Because you know how it is.

Anytime you have change, it's like Mhmm. Overwhelmed. Like, well, where do I take a bite out of this? You know? Where do I start?

Start where your curiosity leads because I think that will that will give you the most interest and return. So if there's an area that as a clinician, as a manager, you really feel like it would be beneficial to have more information. I think starting in that starting in that area is an excellent place to start. And, really, you're gonna find with small effort, this is one of those areas where the the first couple steps give the biggest reward. And so really, it's just finding where you're interested, where you're curious.

Alright. Well, doctor Brian Gietzen, I wanna thank you for joining us on the MGMA Podcast.

Absolutely. Daniel, was my pleasure.

Yeah, mine too. Everybody, we've been learning about benefits based medicine. I'm going to share some different links in our episode show notes so you can learn even more about it. So until then, thank you all for being MGMA Podcast listeners.