Ep 87 Thursday #KareoChat on working in Physician Offices and Dr Rajeev Kurapati Author of Physician

Apr 18, 2018

Join me, Tony Guerra, as I lead the #KareoChat this Thursday, April 19th from Noon to 1:00 pm EST. We are discussing "How can you make the pharmacist part of your [Medical] practice’s team?" The #KareoChat is the most widely recognized Twitter Chat about private physician's practices.

Today's guest is Rajeev Kurapati MD practices Hospital Medicine. He is the author of Unbound Intelligence and Physician: How Science Transformed the Art of Medicine. He holds an MBA from University of Missouri. Dr. Kurapati draws insights from scientific knowledge and spiritual wisdom around the world to provide practical solutions to life's most common problems. His articles pertaining to medicine, culture, and lifestyle have been published in Slate Magazine, Cincinnati Enquirer, Mind Body Green, Life Hack, KevinMD, The Good Men Project, and other outlets. 

https://www.amazon.com/Physician-How-Science-Transformed-Medicine/dp/B079RVHF78/

Full Manuscript:

welcome to the pharmacy leaders podcast with your host Tony Guerra the pharmacy leaders podcast is a member of the pharmacy podcast network with interviews and advice from building your professional network craft and a purposeful second income from students residents and innovative professionals alright welcome to the pharmacy leaders podcast I'm Tony era and today I have dr. Rajiv kotipalli who practices hospital medicine he's the author of unbound intelligence and physician how science transformed the art of medicine he holds an MBA from University of Missouri and dr. chiropody draws insights from scientific knowledge and spiritual wisdom around the world to provide practical solutions to life's most common problems his articles pertaining to medicine culture and lifestyle have been published in Slate Magazine Cincinnati Enquirer mind body green life hack kevin md the good men project in other outlets welcome Doug to the pharmacy leaders podcast Thank You Tony thank you for having me here it's a delight okay great um you said it was okay to call you run chief so we'll guess bad and making a bit of an informal discussion right I don't actually read books I use the audiobook so if I'm referring to chapters or any things they might be a little out of order but that's how I make time to to listen to books like this so I wanted to see if you could just first give us a little bit of your personal background about becoming a physician and how that all came about okay so I'll make it short and sweet I I had this idea you know I'll might when I was growing up and you know what they called the age of reason which is about nine or ten or seven or eight and on the time about nine to ten years of age I developed this this inquisitiveness towards human biology I wanted to know what human body is made up of a human body is made up of human mind is made up of how the interaction happens so that's how the interest started when I would go to the hospitals I would watch these physicians in in few seconds come up with an idea of what's wrong with the patients and in the next few seconds they're already you know designing their plan of how to treat it I was intrigued by this what goes on their mind what's the mystery of of their knowledge and so that's how it all started it's just basically a and extreme interest in how the human biology works and that's how it started and obviously from that time all I wanted to become was a physician it was to become a doctor I didn't have anything in mind I was good at art I used to do oil painting and things like that when I was growing up and then that was more of a side interest and so that's how it started and it would naturally led to you know go into medical school this and that but I grew up in India I went to medical school in India after that I came here I'm into residency residency in the United States and then I also did a master's in business administration I you know me I wanted to become a physician later at some point in life and that so me and a friend of mine got into MBA program at University of Missouri and then after finishing it I got into practice and I do some leadership act leadership activities in our Hospital shade of certain committees and I was the director of our program for a short period before I got into writing and that takes a good amount of my free time which I love doing it for writing so that that's quickly it by the way I've I have a beautiful wife and two little boys profile for that that's my background you know and I show okay well tell me a little bit about how the humanities fit in we'll get into it a little bit later my undergraduate degree is in English tell me a little bit about the humanities did that come after you trained as a physician in medical school or has that kind of remained with you you mentioned art but it sounds like the writing piece what pharmacists want to know is where where does that come up and how do you get good at writing good enough to become a published author humanities is always part of my growing up it never left me I didn't see it as something separate from science see when you look at signs what is signs if you question I this was one of the things I questioned when I was writing this book what is science really science is a data-driven investigation of nature nature in that includes human human beings so when you want to do science on something you need data so the this science or scientific method starts with a question an intelligent guess of what you wanted to test and that we call hypothesis right so you you have a hypothesis or intelligent guess and the next thing you need is data so that without data there is no scientific investigation so humanity's on the other hand deals with those aspects of human dimension that are not measurable right so science cannot reach those recesses of human dimension that are not quantifiable for instance how do you measure feelings emotions fears biases existential crisis midlife crisis how do you measure this there is no way to measure them this is where humanities come into play and I did not have any formal like the college degree in humanities but it was always part of me every time I have a human human well when I have a physician to dr. which is a human to human interactions humanities has to mean it's in the word itself humanities is a human to human interaction science is only a tool for me to know what's going on inside their human operating system but humanities is what helps may interact with the patient if I'm lacking on this dimension then there is no difference between me and a machine treating or dealing with the patient so well as we enter into the age of artificial intelligence and machines and automation this is what makes you special industry especially in the field of medicine where technologists are rapidly progressing and and you know everything is becoming automated everything is run by algorithms so unless you have this human to human connection and the huge bit of humanity's interplay between you and the other person which is your patient I mean there is no I don't have a role to play there and that is what the patient's earn from a physician so that's where the humanities come into play okay well let's actually make this concrete from a story in your book you had a story about I believe a diabetic patient who asked why me best friend that was you know you could you can bring IBM Watson in and then see the you know patient says why me and I think Watson would have a lot of trouble with them can you tell me a little bit about Blaney bringing the clergy in as some help for an answer like that or a question like that and then how it improved patient outcomes in terms of insomnia and those types of things oh absolutely so I talked about a patient at 40 year old african-american who was admitted and who was undergoing who was about to undergo a major surgery which is it which is a life-changing one which is an amputation of his leg because of the diabetes suta infection so dis patients after going through surgeries after surgeries he's um he was on dialysis he was on so many different antibiotics many many specialists heart valve infection he was on long-term antibiotics and so on so he was going to exist into crisis his question to us was why me why am i why am i suffering what have a grande was his real question and our answers was were rooted in science our answers were you are suffering because you have diabetes and then he goes on to say why do I have diabetes because it runs in your family why does it run in your family because their parents had it so there is an infinite regress and until a point where as a person of science a physician as a personal science I would say I do not know why you are really suffering because we reach an endpoint where science cannot reach your question really it cannot answer why a baby or a kid had to suffer from cancer from an incurable cancer how do you explain this to a parent how do you tell the parent your kid had you know cancer and she's gonna die in six months I do not know why I do not have an answer and there is a sense of guilt sense of need for closure for these type of questions in the minds of patients see if I have a common cold or a pneumonia or you'll infection or things like that or to take you don't encounter these type of questions you don't entertain these questions but if you have an incurable illness then a certain sense of existence or crises creeps in and science do not have answers to this so when something like this happens in the hospital settings we bring in a hospital chaplain or a pastor or a priest so that they tap into that dimension of human awareness or consciousness where signs cannot reach and it depends on whether what part of the world you are in you know if you're in this part of the world and you you and your Hospital that happens to have a hospital chaplain you bring them in if you're in the eastern side you bring in some other priests you know of that particular Hospital so you have to have both the scientific side and the humanities side to treat the patient so that is that is how I had to bring in the hospital chaplain and suddenly I mean and if in a few days we started seeing certain changes in this but in a positive way in this patient where he's not asking these questions anymore because he seemed to have found a closure to these questions whether they're right or not is a different matter but he happened to understand that okay I'm suffering because of this piece and this reason and then that help the patient to cooperate with us and you know when you psychologically heal you physically heal now you see that studies after studies so that's that's where this patient comes into the into the picture that does it does it make sense yeah no absolutely and and appreciate that I just it was just something that really stuck with me you know even a month after I I read the book and and how that you know getting that shock of I don't know and then being able to say I don't know well maybe let's shift a little bit to working with other health professionals you're a hospitalist tell me a little bit about how you work with maybe nurses and pharmacists within the hospital as a team you mentioned in the book that before physicians were the pharmacists and the physician you know they would dispense the medications then that kind of went away but now it's coming back a little bit where physicians inundated with EHR copy and paste you know people would copy and paste into the EHR so you have you know all to read and not enough time to do things how do how do you think physicians are able to best employee nurses and pharmacists to help give the physicians the time they want to do diagnosis to to do the things that they want to do that's right so if you look at you know as part of this process and writing the book I've read back all the way to let us say 650 BC there Pythagoras from dating back from Pythagoras to the present and moving into the future so this book covers the entire spectrum of evolution of medicine and its practices and going into the future in a nutshell I mean this doesn't involve nor in enormous detail but then it gives you a bird's-eye view a could a big picture of how medicine has evolved so with that in mind if you look at the ancient physician and and let me let me put it this way if you look at how health care is provided by a physician to the patient the first step is identifying the problem we call it diagnosis and the second step is either depending on whether it's a surgical or medical if it's medical you dispense the drug so in the ancient past like diagnosing and dispensing was done by one individual and he was usually a priest and a philosopher - this person was a polymath he was all in one he or she it was all in one so as we reached the scientific revolution in the sense 16th and 17th century specialization started to happen so when specialization happened we moved from a holistic model of healing to a DC centric approach you see centric approaches the problem is in the organ you identify and diagnose it and treat it so when this happened enormous volume of knowledge started to and upon the physician and she fears she couldn't handle this this volume of knowledge specialization happen and he was responsible for diagnosing and prescribing the medications but dispensing had to be done by somebody else because of the complexity of the medications that were involved the interactions between the drugs the physicians could not he you know handle the specialization in the complexity of the drugs and so the pharmacists emerged it is an offshoot of the physician actually of course you know the the drug makers also collaborated with physicians in the beginning but then the collaborative agreement had to fall apart they could not have a financial relationship with each other so edicts were passed in first Germany and then that went into Great Britain and the rest of the Western Hemisphere had to follow certain rules and regulations how the physicians and the pharmacists work together so physicians have strictly prescribing role and pharmacists have strictly dispensing role but if you see what's happening now physicians and pharmacists or becoming or starting to develop a collaborative agreement again where the pharmacists are allowed to diagnose and dispense medicines diagnose order test prescribed and dispensed medicines for a certain conditions like for instance we have seen quietly anticoagulation clinics like it is solely run by pharmacist as providers so they are the providers for that so there is no physician involved in it and see all this comes to three things in medicine I'm backing off a little bit here to give the audience a better idea of what all this is about health care stands on three pillars one is accessibility affordability and quality of care right so you have to have good accessibility of healthcare if I need my iron art checked if I am on warfarin and if I have to run to a physician all the time then there are not enough physicians who can you know who has squeezed in that amount of time and so accessibility suffers so they have opened up coumadin clinics and improve the accessibility affordability so it's not enough to have to have accessibility and quality of care if it is not affordable the third one is the quality of care so we took these three pillars we see that the collaborative agreements between pharmacists and physicians is only going to expand because we need more providers and pharmacists are in a unique position because they are part of the team players in a health care team and they are in a unique position to provide not only dispensed but in the future I spoke to some of some of the pharmacists in our Hospital and they feel like in the future for some specific diseases they will be allowed to diagnose and dispense medications so I mean the relationship is very unique and an inseparable ok well that's a I hate jumping around in the book but but your the way that you know we're talking I feel like we're gonna go to the future I want to talk a little bit about the AI component of the book which is closer to the end but so IBM Watson comes and says that you know we want to be a partner with you and and this is really your third pillar the quality of care and in some some cases I guess it would be affordability but so for example radiologist looks at us a film and then a second radiologist looks at it you're going to get a better result but now a I might be that second radiologist tell me a little bit about how physicians are looking towards AI as also being one of the partners in improving quality of care that's a great question because it is going to happen artificial intelligence is going to take over the rules some of the rules of the current day physicians it's and it's already happening look at pacemakers look at EKG machines in the hospital's see they say that the first like you you raise the radiologist example they say that the first branch of the specialty to get hit by AI is radiology why because it doesn't involve as much human to human interaction as other fields of medicine are and the one field that is going to survive AI the invasion of artificial intelligence is psychiatry or psychology because that involves human to human interaction so when artificial intelligence takes over or when it starts to take up more and more duties or responsibilities of the physician what it really means is it is standardizing care across the continuum using all the available data in that particular field for instance if a person goes through a surgery for example an appendectomy right so when AI comes into picture it will take in the specific data from that particular individual compares it to data from all the available data across the medical literature and it will take in not just the population statistics it'll take in for this particular age group in this way train wait wait you know range for this climatic conditions how is this surgery going to affect the person if the person asked when can I go back to work how much weight I can lift the current standard of recommendation is based on population statistics and it is it is it is only a crude estimation of the reality for that particular surgery in other words a is gonna give you personalized data a is gonna tell you for you you can go back to work in five days but so this other person he cannot go back to work for 10 days because of this this and this reason we have gathered data from all the other available resources with you in mind so AI is gonna give you accurate personalized date information based on your matrix but it is still based on matrix as we discussed in the beginning of our discussion science and artificial intelligence is based on those aspects of the care that can be measured but it is going to give you a whole lot of options and you need a human professional to interpret that data and apply that data to you because at the end in the in the end and you know you have your own believes you have your fears and biases and and your going through certain crisis in life and you need a human to human interaction to interpret the data and provide you with the best possible outcome so AI is definitely going to take over but there are certain aspects of the profession that are going to get hugely affected like the bread and butter practice of primary care physician is going to be hugely replaced by artificial intelligence but psychology and certain aspects of care are going to survive that okay well let's actually talk a little bit about outcomes in your book you talk about how the way that insurers look at something they look at it as an epic net daily was completed we're going to pay for an appendectomy regardless of this is physicians first surgery or this is 20-year physician doing surgery expertly with better outcomes can you talk a little bit about how this outcomes model team base is going to kind of change how things are so that you know it's it makes more sense where someone who's been out 20 years provides much better outcome gets better reimbursement versus getting maybe a lesser quality of care it's kind of going back to your third killer again yeah so what we have now is a person who is fresh out of his residency he's fresh out of training is paid the same you know pay paid the same amount for the same procedure as a person who is in practice very experienced let us say 25 years in the practice so there is no reward for efficiency so definitely you you can't say the person who is fresh out of residency of three or four years of training has the same skill as a person who's been doing this for 25 years right that is your question yeah yeah yeah yeah so then more and more data the big data is collected and put in national registry when it's more and more accessible to people they will be able to see how many years of practice what's their success and failure rate of this physician and then that happens automatically the you know third-party providers so the insurance companies are going to reward you know the physicians with the higher efficiency more experience I think it is it should be that way because what's the incentive well we're talking about the financial incentive right so there's there's always the humanistic reward that you you know your patient thank you for doing such a good job but then you have to run your practice too you need you need the the numbers the finances to meet the overhead and pay the bills and run the staff and so on and so forth so I I feel that the the more data we have in the future about the physicians work practices and it is going to happen the more they'll be rewarded I don't know if I answered your question normally you you you you did and you did okay well I wanna I want to keep this around 2530 minutes I usually keep dancin to it on the commute but what I want to ask you as maybe a final question is when I looked at your book and I looked at the chapters I saw it and maybe it's a bias because I I'm teaching in a college but I saw it as you know 18 chapters oh that's gonna fit nicely into a 15 week semester can you tell me what audience you would have in terms of or what a course would look like if they were to use your book oh well that's that's a great great question I mean at that's I didn't mean to catch you off guard I did I immediately see a book and it's either it fits well into the you know semester curriculum or it doesn't and this one it's just taking a couple seconds to think through you know what's the structure so see if the way I looked at the book is it's actually two big parts divided into subpart the first half of the book or the first 60% of the board he's about the evolution of medicine from a priestly profession to a scientific one okay so how did the priests become a person of science what changes happened within the scientific community or within the medical community for it to transform from a philosophy into science okay so that's the first half of the book at in in the India if so I I divided that into how this disruption happened somewhere in the sixteenth century so I laid out from 650 BC from Python starting from Pythagoras in the Greek tradition so this book is primarily about Western medicine all right so this is not I I introduced a little bit of Eastern medicine the reason why I didn't dwell much into the in the Eastern medicine is because not much disruptions happen in the Eastern medicine so if you look at Chinese medicine or Indian oil whether a Chinese acupuncture and the holistic healing not much disruption really happened they still use the same text books that were written 2,000 years ago but major disruptions really happen in the Western medicine so how did that transformation happen what really happened in the 16th century that made them to break away from the 2,000 year old tradition of humoral practice which is balancing the fluids which was started by Pythagoras and his predecessors and completely disrupt the practice of medicine and break away from tradition and become a scientific one so that is the first half of the book the second half talks about different aspects of how medicine changed since that time since the 17th and 18th centuries how did the insurance came about how did the pharmacist the the how did the pharmacist profession you know arose and and how did the nursing did the nursing change at all for all these 2,000 years and so the second half of the book talks about the aftermath of the Scientific Revolution and the last chapter talks about what's going to happen in the future and I concluded with some notes to the fellow practitioners so that that is I mean so the first half and the second half and then within the first half talking about they will use a medicine from a priest to the scientific one and the second half from the scientific one from 18th century into the current and moving into the future okay well I've asked you a lot of questions is there anything you want to say that I haven't asked you about um I think we covered a lot of a lot of subject I might have gone a little overboard on some of them [Music] because once I stopped talking I get really passionate about these topics and and kind of go off the tangents sometimes but I'm glad I we covered a lot of lot of topics maybe we can have another discussion about some of the things that you felt might help the pharmacy students or some other aspects of care that we can talk about see some of the things that we might have talked about is how low can pharmacy students collaborate with physicians in the hospital how can they become better team players you know things like that yeah that sounds good we'll definitely have to have you back well thank you so much for being on the pharmacy leaders podcast show thanks a lot for having me