Ripple of Change: Dr. Todd Otten

Today I'm speaking with Dr. Todd Otten, who is not currently in Maine but does have a Maine connection. Dr. Otten is a board certified family physician with over 20 years of experience in healthcare. As a co-founder of Our Quadruple Aim, he is dedicated to challenging the status quo in healthcare by promoting patient experience, quality care, lower costs and provider wellness. Todd's distinguished career includes recognition as a naval flight surgeon of the year in 2006. He co-authored Ripple of Change, a book that he wrote with his patient actually sharing insights on burnout and systemic dysfunction in the industry. But really that's just part of the story, Todd, because I think what I'm hearing from Ripple of Change is that you're looking for kind of a positive way through. Correct me if I'm wrong. And welcome. Well, and thank you for having me and you are spot on that we need to find a positive way through. And I often say that I'm a positive disruptor, I suppose. And really what we were trying to accomplish with the book was to inspire and empower everyone to play their part. I think if we have patients, clinicians, administrators, if everybody does a little bit of something in a positive direction within the healthcare space, we can really start to move the needle. But it's going to take a lot of us for sure. When I read your book, which you co-authored with Joshua J. Judy, there are many pieces of it that I could certainly relate to. I mean, you and I share a long, similar parallel paths in family medicine for one thing, but I also think that many of us who have gone through and have been practicing for a number of years have experienced the ups and downs and probably more than once, of working within a system that doesn't always seem inclined favorably toward people who are trying to provide care, nor does it seem to be inclined favorably toward people who are trying to receive care. But I'm interested in part because I think that what you wrote was probably one of the best descriptions of actual burnout and probably recovery from burnout that I've probably ever read. So talk to me about your experience with that. I know it's kind of a trigger word these days, but what you went through was very powerful. Oh yes. Even just every time I go back to it, in my mind, it brings back some emotions. I love being a physician, I love seeing patients. It's such a joy. And when the days are going well, it's magical. It's like the best job in the world. But you're right, there were instances, particularly in 2019 as this transition was going on where I was starting to struggle with burnout. And at the time, I think subconsciously I knew it. Maybe I didn't want to admit it based on training or what have you, but I was getting short, I was getting angry, I was getting frustrated. The happy go lucky, enjoying the day, trying to inject humor guy had slowly disappeared. And I distinctly remember sitting in my backyard in tears hating the job that I loved. I mean, I hated it. I hated going to work. I hated seeing patients, and these are people I loved. I had taken care of for a decade at this emotional, just talking about it now, it was hard to describe, but I think the reason I started writing, I think initially was the catharsis for myself. I suppose it took a good two years to really recover from that episode. And this was with counseling and this was being more open about it. I mean two years to get back what I thought was some semblance of normalcy. I wrote a poem called Medicine is a World of Gray, and it was kind of a really dark, somewhat despondent look at what really happens in primary care on a day-to-day basis. When I wrote Anatomy of Burnout, that was the start of some healing for myself. But when Joshua Judy got involved with this, it took on a very different trajectory in terms of burnout and what we were trying to accomplish and what have you. So yeah, burnout is a raw, real painful thing that you can put other tags on it. You could call it depression, you could throw in moral injury for sure. But having lived through it, I can see why many of our colleagues ultimately don't and are no longer with us. And that's a tragedy. Even your willingness to write this down and put it out there and say we need to have a conversation around that is so powerful and important because I think in medicine, the culture is such that we are expected to care for others. And from the very beginning, the emphasis is on caring for others at our own expense and actually at the expense of our family members and our significant others and others around us. And although it's a wonderful mission and I have loved working with my patients over the years, it creates this dissonance where you never feel like you can actually speak about your own emotions. You can never bring forward your own experience, and it becomes this thing that kind of turns in on you over time and then is kind of hidden and then it gets perpetuated by not talking about it with anybody else. So I think your willingness to bring this out and be honest about it, even as you are seeking positive change forward, that says a lot. And I am wondering if you've had any interesting interactions with other people who are in the medical field as a result of putting this into the world? Oh, for sure. It's, the last year has been an amazing interesting journey since we published the book. Being a physician, you're not an expert writer and you don't know how to publish and all these other things. So we had gone through that whole process relatively successfully. And frankly, I didn't want to be censored. I didn't want an editor telling me what to say. And so Joshua and I pretty much did it all on our own with some help of some key individuals. But once we published, it was like, okay, great, what do we do now? And it was really when I got on LinkedIn amazingly enough that I started to have just conversation after conversation with our colleagues around the country and really actually around the world now who are experiencing similar things and are clamoring to talk about it, are wanting desperately to have resources to deal with it themselves and are so appreciative that somebody, and not just me, but there's many of us out there who have started to talk about this and are so appreciative that we're being honest and getting it out there, and now they feel empowered to take action or to say no or to push back on some of the ridiculous clerical burdens that exist. And that's just one example. It's been in the hundreds of our colleagues I've talked to and maybe even more than that at this point. It just fills me up to realize what initially started as maybe a labor of love and some catharsis for myself has created a vehicle for others to do the same. And it's amazing. I am almost speechless at times thinking about the impact that Ripple of Change has had to this point, not just for myself, but for my friends, my colleagues, my family who have had some healing as a result of it. Todd, do you think that Joshua had any level of healing around this? I mean, I think in the end, my understanding is that you no longer are practicing in the same place, so you no longer have the doctor patient relationship, but he had his own complicated relationship with medicine and healthcare. I'm not asking you to speak for him, but in your conversations with him, did you recognize any level of healing there? Oh, 100%. And it's probably worth telling this story a little bit how Joshua got involved with the book in and of itself. So I had been caring for Joshua for about a decade when the book was really going full steam, if you will. And I created a mess for him from a health perspective with a medication that I wrote for him with devastating side effects. And it got even worse when he tried to come off of it with the withdrawal syndrome. It was an SNRI. And ironically, it's the exact same drug that I take for my post-concussive headaches. And so I was literally running out of ideas for him. We had tried injections for his neck pain, he had cervical radiculopathy, and for the casual listener, that's a pinched nerve in the neck causing pain down the arm, if you will. We had tried referrals, analgesics, physical therapy. I mean he traction everything under the sun. And so I had had a decent response or actually a pretty good response with the oxetane for neuropathic pain, meaning nerve pain and for it to him, and it just created this mess. And so as we're going through this and I'm struggling to figure out how to help him, I told him about the book. Joshua is a very bright guy, very articulate, big heart, good dad, all that kind of stuff. And I started telling him about the Quadruple Aim, and he's giving me the deer in the headlight looks like, what are you talking about, Dr. Otten? What's the Quadruple Aim? But he had enough belief and faith and wanted to support me that he seemed interested. And he's like, well, what do I write about? And I literally just said, just write. That was my only instructions to him. And so he did, and he wrote a very beautiful piece that's actually in the book about his son in an ER visit. And from there we had a meeting and we talked about my vision initially, and it was really when he got involved and we talked about the yin and the yang, which was Joshua's idea that it took on a very different trajectory. And the target audience became really massive at that point. And it wasn't being written towards physicians and administrators. It was being written for everybody to say, okay, what's really going on behind the scenes? Why are patients frustrated? Why are doctors miserable? What's happening here and how do we take it to a different place? And so yeah, it was magical. And back to actually answering the question I suppose, which was did Joshua get some catharsis out of it? A hundred percent. A hundred percent. So there was a point where a little bit further down the line, he had come back in for a visit and I told him, Joshua, I believe you're going to get better, but you have to believe it too. And I'm tearing up just thinking about it because he did start to get better. He did have the catharsis of writing. He did start to deal with his emotions and do some other things to fill up his cup. And is his health perfect? No, I mean he had to go on testosterone, add Synthroid as a result of side effects from another drug, but is he in a better place? Does he appreciate balance? Does he set boundaries? Yes. And he would absolutely tell you that. And our relationship went from doctor patient to, I consider him a brother. I love the guy we text each other daily. It's just been an incredible ride. One of the things that I've thought a lot about over the last, say 10 years or so, is how we balance the absolute need for privacy and protecting patient's stories. And to some extent, I guess protecting maybe our own stories, but also the absolute need to share stories. I mean, Joshua obviously co-authored this book, so he's sharing his own medical story so you're not violating HIPAA because he's talking about himself. And then when you're talking to me, you're talking about something that Joshua has put out there. But I think as HIPAA was very this rule that made it so that we really shouldn't be talking about anybody with anybody other than the person themself very important. And in data privacy time, absolutely. But I think we've lost something. I think we've lost the ability to learn from stories that we maybe might've shared once in let's say the doctor's lounges that used to exist before everything went digital. I agree with you, and I think in medicine, things have gotten to be very black and white, and that whole gray area where medicine exists has been frankly lost at times. And when everything is seen as yes or no, or as I said black and white, it causes problems. And I think there's ways to continue to have the conversations but also respect HIPPAA, right? As an example, the book is full of things from patients that they said or stories that are similar, but take out the key identifiers, change the names. Call it person blue sky, be creative with it. And you can still have those moments of healing. And honestly, there were a lot of my patients that specifically wanted their name included in the book, particularly with the jokes that were included and very much we're advocating for it. And so I think we've lost our way a little bit in that regard. And I think we need to realize that medicine absolutely is a world of gray, and we need to be thinking about how do we navigate those waters and allow for healing with not only with patients, but with our colleagues, because we cannot continue to have a physician a day dying in this country by their own hand because of the way the system has been set up and organized. I mean, that's a tragedy, and it results from all these layers of things that we're talking about, the fact that clinicians at times feel like they can't discuss a devastating case because of hipaa. We got to work around that. We have to do better. We just have to. And you're referencing something that I think many of us have been touched by and also doesn't actually get discussed. I mean, here in Maine, we have absolutely had physicians die by their own hand. And I've known many of them. And yet even that doesn't really get talked about because, and maybe it should be some sense of shame that we in the healthcare setting actually have over not being willing to talk about it. But when someone follows through a suicide, there was a whole trajectory that led up to that point. And so by not talking about it at all, it kind of continues to place the blame squarely on the shoulders of that individual. And that's just not really fair because I think particularly in medicine, although certainly other settings where people do follow through with suicide, it could also be true. But in healthcare, there are a lot of things that are stressful that on a daily basis are contributing to people's inability to just make it through and see light on the other side. I agree. And I think these conversations are so important to continue to talk about it and make the average American aware of how big of a problem this is. So I talk about it a lot and it's become sort of second nature for me to be talking about the issue of physician suicide. But when I bring it up to somebody who's not a physician or pretty well versed in the healthcare space, they are shocked at the rate that they can't believe it. And I'm like, yes, this has been not only happening now, but it's been going on. And there are so many factors that contribute to it. And I think unfortunately, the way our system is set up with profits over people in the vast majority of instances and churning out numbers and RVU and volume, all these other things, it is just going to continue until we reverse some of these things. But having said that though, I don't want to dwell on the negative, but I think there's many wonderful organizations out there who are working on this. The Lorna Brain Foundation is a perfect example of this based on the unfortunate passing of an ER physician during the COVID Pandemic, the Medical Society of Virginia and their work with Safe Haven and several other states that are starting to work on those real barriers to mental health treatment for clinicians. We can start to turn this around, but I think that's just part of it. I think the emphasis on frankly, money at the core of healthcare delivery too often is a big, big problem and needs to change. I tend to agree with you. And having been in senior leadership positions sitting in the c-suite, I have an understanding as to why we have gotten to that place because I also know that the current healthcare system as it's structured is very tenuous. So money gets put out there as the most important thing, which then kind of trickles down, and you have people who are working towards productivity and they're trying to churn people through. But then I've also sat around the boardroom table and I hear about multimillion dollar deficits that healthcare systems are struggling with. So I would suggest that we actually need to be thinking about solutions as to how we think about healthcare differently, how we fund healthcare, how we reimburse healthcare, because I think there are a lot of people who are trying to solve a problem that was created by a lot of different issues all at the same time. And I personally, this is my opinion because my background is both in healthcare and in leadership and I have a doctorate in leadership studies, I personally believe that we need to be leading differently in healthcare so that we could come up with different solutions in healthcare so that we can address the fact that money is necessary to keep the lights on. And also the way that things are structured now to create that money is killing people. And it's not just killing the physicians who may complete a suicide, but other clinicians, advanced practice providers, nurses are feeling the stress people on the front lines, EMS. So how do we do that is my question. I mean, you are working on this Quadruple Aim, and I love that you're doing the Ripple of Change. Tell us about the Quadruple Aim and where do we start with all of this? For sure. Actually, my mind was going in a couple directions related to this. I often joke that I agree with you, we need to be working on solutions and not just talking about the problems. And I often will joke that we're trying to build the airplane as we're flying, which I guess this might be a good time. I had a prop from my time in Brunswick, Maine. I love it. But to answer the question, I think there's a lot of different ways we can deal with this. And I'm a big fan of the Quadruple Aim in its simplicity. And in the book we call it Our Quadruple Aim because we want everyone to feel like they have ownership of our healthcare system in one capacity or another. So the four tenants are patient experience, quality care, lower costs, and provider wellness. And I'm fully aware that provider is a very triggering word for many individuals. In retrospect, I'm kind of glad we used it. It gets people thinking differently and talking and challenging the status quo. So if you don't like provider, change it, healthcare, professional, clinician, physician, whatever's appropriate in the moment. And really that's what we want people to do with our quadruple aim. It's not meant to be black and white. It's meant to be molded and malleable and used in whatever your situation is to make it work. Because when you really pay attention to those four tenants, which is akin to the quintupling, when you throw the R in front of it, which is the health equity piece, and I know I'm throwing a lot of stuff out there, but it can be magic. It can be magic. I've seen it work, I've seen it work at the office level, I've seen it work at the hospital level, the system level, the ACO level. And I think if we start to get the right framework and foundation, if you will, it could work at the national level. What is one of the ways that we're going to do this? Well, I think I've got some colleagues who are working on building towards an impact network with the healthcare reinvention collaborative. And I think there's going to be little pieces to the puzzle that come from different entities. There are so many wonderful organizations around the country trying to do positive things. Unfortunately many of them are doing them in their own little silo. And we've got to learn how to take and share the best from one another to come up with the ultimate solution. And I don't think it's going to be one thing. I think it's going to be a whole host of things, legislative changes related to credentialing. Direct primary care I think is a fascinating model that might play a part to this. There's talk of community-based care delivery and an example of housing being connected like the work Mark Smiley's doing in North Carolina. So there's all these little pieces around the country happening. I think if we can get an impact network together where people can share best practices and what's working in certain instances and then celebrate and shout those things, that's when I think we're going to start to see some real in the right direction. There are many areas that are doing wonderful things and we need to celebrate those areas. So that's my vision. So I don't think there's a simple answer to this. I don't think it's a flipping of the switch, if you will. I think it's going to take a lot of work of of people collaborating and ultimately getting to policy changes that are for the benefit of the majority, not the few. I agree with you and a big part of the work that I do that's related to leadership, but also practitioner wellness, and that's the word I just happened to have picked because it seems to make sense to me. I also agree that provider can be very triggering because there's just seems like almost a very nondescript way to describe people that I have spent a lot of time and effort getting their educations and learning how to care for people. So I think it was an insurance company term, and that's probably why it triggers people. So I use practitioner. It can be very divisive for sure. Yes, absolutely. And I personally think that this has everything to do with learning how to communicate, learning how to communicate both within the medical profession but also outside of the medical profession, not making an assumption that because we are in healthcare, all of the solutions have to come from within healthcare. Understanding that other professions have equally valid, if not even more valid approaches to things like let's just say burnout, maybe moral injury, but certainly healthcare, economics, health equity. And I think one of the things that we may not have emphasized quite enough in the last, let's just say 20 years, is how do we actually talk with people in different ways outside of medicine? Because my specific experience in training was very much still in the doctor at the top of the pyramid, doctor is God model that is probably a century old. And I don't think we can live there anymore. I think we need to understand we are not the gods. Healthcare is not the heaven. We all need to be able to talk to one another. And that means me talking to you across the country, you talking to people around the world and talking to different people no matter what their specialty is. So how do we help people communicate with one another? Well, I think again, there's probably a lot of layers to the question here. I think active listening is key. I think relationships are key. I think being open-minded to other possibilities or solutions is key. And it's not that you need to agree with everything, but for goodness sakes, you really should at least listen. And as a physician, I think one of my strengths was the capacity to tell my patients when I wasn't sure or that I didn't know and I needed to get help or we needed to order a test. Forcing something into a box has happened way too much in medicine. You can even see it with diagnoses that come out of pick an area. And I won't get into examples, but I think you are spot on that we need to learn how to work with other industries. We need to think about how new technology is potentially going to play a role in this. And don't get me wrong, I'm not saying technology is the answer. I think the human interaction in healthcare, that relationship is the most powerful thing that exists. And I don't believe that's going to be replaced. And I'll go back to the book, the relationship that I have with Joshua and the healing that we both got out of our relationship. You can't replicate that with technology. I don't care what you do, you're not going to come up with that. And I seriously doubt chat. GPT is going to come up with a prescription to just right is the only thing you tell the patient. But having said that, I do think generative AI is going to play a role and be beneficial. There's going to be pros and cons to that. And I think there needs to be human oversight. I actually believe the blockchain has a big role to play in this, particularly with medical records and access to information. But the existing silos, perhaps the simplest way to think about this is silos are pervasive in healthcare right now and they create so many problems I can't even begin to describe it. And that needs to go away. And we also need to pull down the silos and the walls to other industries that have insight to help us get to a better place. So I envision the solutions are going to come from a much more collaborative space. And to go back to the leadership component too, I think we need clinicians, physicians, nurses, pharmacists, medical assistants, whatever at the highest levels of leadership who are in it for the right reasons, whose altruism exceeds whatever WIIFM they've got to help lead us out of this mess. And maybe I'm overstating a little bit, but I truly believe that's going to be paramount. And I tend to agree with you. And I would also say that traditionally the way we've approached leadership is the people who lead are the people who have been assigned to the leadership role. And it doesn't necessarily correlate, certainly as physicians, I think you and I probably were given the benefit of you have a doctor in front of your name, so therefore you must be a good leader. And I think that understanding that there are actually skills and attitudes, knowledge, behaviors that can lead to more and less effective leadership and not simply just going with this is what we've always done from a management standpoint. I think that's going to be important moving forward. Well, and the other thing too, and this has been very clear to me in the last year or so, so much like you, Lisa, you've probably always been in leadership positions, I'm guessing throughout your life. And if I'm wrong, forgive me for that. But I've always found myself in leadership positions, even from high school when I was a supervisor at Parks and Recreation up and through the Navy and into residency and beyond. And as a young physician, I got put into leadership roles that I was not expecting to be in at all with mergers of hospital systems. And I've only been to the place for like a year. The point I'm trying to make though is in the last year, it's a lifelong process of learning. And I think the best leaders are the ones that are willing to have that introspective look and say, oh boy, that wasn't the best what I was doing 10 years ago, being an accidental diminisher or hijacking a meeting or having blind spots when it comes to this, that or the other thing. I think the best leaders are the ones that take that stuff on board and say, okay, how can I do better? How can I serve others better? How can I become a better servant leader? And in the last year I've really tried to take a lot of those things on board and it's been fun. It's been hard at times. There's been some frustrating moments for sure. But it's great to learn something new and meet all these people. And I think the other thing that I just find just so uplifting, there are so many great leaders out there who feel trapped and we've got to help empower those individuals to get in the right positions to get their voices out there really to make a difference. Yeah, so there it is. I don't know, it just, there's a lot packed into that I suppose. But sometimes I just get on a roll. At the end of the day. I think what you're saying is true that this is, we're talking about a complex system that's gotten to where it is for a variety of complex reasons, not all of which are from within actual medicine or healthcare. And it is going to require a lot of people working on it in a lot of different ways. And I think for me, trying to understand as a leader and also working with other leaders, the path forward is going to be more collaborative, is going to be more of a transformational mindset versus a poverty oriented mindset where you're thinking, oh no, we have to keep doing what we always did because we don't know what the future looks like. I think there's going to need to be more agility, more flexibility of thought as we've already talked about, the ability to communicate with other people. And I think of leadership honestly as a practice the same way that medicine is a practice. Because what I came into being a doctor with was just the beginning of what I've used over the years as a doctor. And leadership truly is no different. But we can't expect people to know how to do this until they've spent time practicing and without actual reflection on what has occurred as a result of leadership behaviors, we're not going to move any further forward. Well, and I think to piggyback on that a little bit, I think we're in a climate where failure is seen as the end game for this, that or the other thing. And if we're going to move the needle in healthcare to a better place, there are going to be failures. And I'm not advocating that we want to fail, and I'm not advocating that we want to make big mistakes, but I think we also need to be understanding that and appreciative of that they are going to happen and we need to learn from them and take it to a better place. And I'll give you an example. I recently took a part-time job with an emergency physician group in Grand Rapids called Emergency Care Specialists. They've been around for 40 years. It's physician led forward thinking, very much believes in the quadruple aim and value and patient experience and wellness and all these other things. And they talk about that and they're upfront with it like we're going to take some calculated risks. We're not going to take risks that are foolish. We're going to take risks that we think are going to benefit the patients and going to benefit the clinicians, provide better access and better care. And are we going to fail at times? Yes. And we're okay with that, but we're not going to stop trying. And that kind of attitude I think needs to be replicated at the highest levels and appreciated at the highest levels because currently you look at the number of deaths related to medical error in this country, depending on your sources, anywhere from quarter million to 400,000 per year. We're failing on a pretty regular basis with what we're doing. And so we got to think differently about how when we make these changes that we're going to screw up sometimes and we're all human beings and we've got to learn from it. Yeah, I absolutely agree with that. And I think that the other side of doing say our root cause analysis and having it come down to a person's fault, which it almost never is. I mean there are some people who make bad choices as clinicians or any other role that make it absolutely that person's fault. If you cut off the wrong leg and you're the one with a scalpel, that is probably your fault. However, a lot of systems things lead up to this, and I think this idea that we find the one person to be the scapegoat that just always keeps us on this us versus them, it's somebody else's fault. We're not going to try to work on the system because we found the person who created the problem. And so you're right, I think understanding what that looks like and being willing to fail because failure is learning, failure is learning and growing. And if we don't make changes, I worry that my son who just finished his emergency medicine residency, that if we don't