Episode #7 - Ara Feinstein - Insights on Peer Review

Insights on Peer Review from Dr. Ara Feinstein, Trauma Surgeon.

  • 00:10:11 - 05:10:11

    Jerrod Bailey  00:13

    Everybody, welcome to reimagining healthcare a new dialogue, risk and patient safety leaders presented by Medplace. We're excited to bring you conversations with top risk and patient safety thought leaders from organizations around the country, please subscribe to get the latest news and content. And if you found value from this episode, please share it with your colleagues to create meaningful dialogues and your community. Also, if you're interested in participating as a guest, please send us an email at speakers at Medplace.com. And so today, I'm really happy to introduce you guys to someone that's been an advisor to Medplace, really since our inception. Dr. Ara Feinstein joins us today. He's a top trauma surgeon in a large hospital system. He's got a ton of experience, I'll let him give you a little bit of his background here. But yeah, the era has been really advising Medplace from a clinician's perspective, from the get-go, really, in terms of how we're approaching the market, what we're thinking about things. So it really valued his insight and era. Thanks for joining me today.

     

    Dr. Ara Feinstein  01:24

    Well, thanks for having me. Great chance to talk about some things that you and I are pretty passionate about, including things like peer review.

     

    Jerrod Bailey  01:35

    Indeed. So for everybody, or anybody who doesn't know you, and you've got you've got a strong online presence, I would say enjoy watching the types of ideas and things that you put out there. But can you tell us a little bit about yourself?

     

    Dr. Ara Feinstein  01:51

    Sure. So I'm, uh, I always start by saying I'm a trauma surgeon by trade, still like to be in the trenches, taking care of people. And I think, no matter what I do, that's sort of how I identify. And I think that that's what probably informs most of my perspective on things still being that real boots on the ground, and seeing patients and talking to other doctors and talking to nurses and just really understanding healthcare at that level.

     

    But then I also, I'm really lucky to support the whole range of adult specialists for a large, integrated health system called Banner Health here in Arizona. And so I get to work across the system, I get to understand how different specialties work and what different physicians need in their practice. And then I get to kind of, also take a look at how that healthcare system evolves and work with my insurance division partners, and really get my sleeves rolled up in how healthcare is working, and sometimes not working.

     

    And that I also have a master's in public health so that that part of my education, I think factors in a lot in that healthcare transformation piece. But I also realized that healthcare is going to need to be changed from the outside, and that there needs to be innovation, and companies that are more venture based and agile and trying to solve problems that we might not see as well internally. And I think that's a great segue into this conversation and why I've really enjoyed the work with Medplace, because I think that's exactly what you guys are doing.

     

    Jerrod Bailey  03:52

    Yeah first of all, it's been helpful as we're been assembling this large group of specialists around the country and their different backgrounds, it's been helpful to be able to leverage you for you know, how we do that appropriately.

     

    But it's also great to think about with you; what healthcare look like 10 years from now and 20 years from now, in often, those of us who have been in it for the last couple of decades, it's hard for us to imagine how that might look different. And there's certain things and certain modes of operating that have kind of been the same for the last 50 100 years so trying to imagine a different future can be a little challenging some time. And I think that when these innovative technology companies come in sometimes that can help just inject potentially a little bit different thinking into that process. But that's certainly I think, something that even though you've been in the industry for some time that you have the ability to sort of Imagine something that's maybe a different version of the future.

     

    And so one of the things that you and I talk about is peer review, and what that looks like, and sort of what that is today as an institutionalized process within every hospital. But also in what, what's great about it, and then what, sort of has hasn't, or maybe isn't great about, it's one of those sort of universal things where if I talk to 100 doctors, they'll all complain about their peer review process. And it's odd to have this sort of function that sort of universally sort of critiqued in yet I would say not enough solutions to sort of maybe consider how it might be changed in the future. So, anyway, so that's kind of the our topic today, you want to you want to chat with me about that?

     

    Dr. Ara Feinstein  05:54

    Yeah. Well, I mean, I think the first thing that you mentioned is this idea that healthcare is going to look totally different in 10 years than it looks right now. And I think if you asked most of us what the most important change that we're going to undergo well, we're already undergoing it, it's really the transformation to value based care. And you hear that term thrown around a lot. But in the context of healthcare value, the value equation is some version of quality, over cost.

     

    Value equals quality over cost. And so this idea that we're going to prioritize healthcare in a way that improves quality, while lowering cost, is it just permeating everything that we're doing in the way that we compensate physicians, the way that we grow our organization on the insurance side, obviously, it informs a lot of the way we approach treatments. But what I'm seeing in, in the startups space, and in the innovation space, is that a lot of companies are figuring out how to get movement on that equation, right.

     

    And so when we talk about peer review, we are unquestionably talking about quality. And peer review is a huge component of the quality process at any healthcare institution, whether it be you know, hospital, an office, a training program, whatever. There's almost always some version of peer review. And so the question of how do you make that better? And how do you make it? How do you adapt it to this new world we're going to be living in I think, is a great is a great question.

     

    Jerrod Bailey  07:54

    Yeah, well so let's explore that. You know, one trend that we see is it maybe I'll start with maybe more of the problem that I think we're all sort of aware of is that peer review is done today. It's often involving internal resources, reviewing each other. And well, that can be wonderful and a wonderful practice and is, if it's the only way that peer review is happening, I think we're seeing the sort of the chinks in the armor in some of that, right? We're seeing I mean, if you've seen it, too you've got, you've got partners reviewing each other, you've got competitors reviewing each other, and the data that comes out of that process isn't necessarily data that's helping anybody.

     

    Dr. Ara Feinstein  08:49

    Yeah, absolutely. I mean, I think it's the right to trial by a jury of your peers, but in, in the legal system, if you know those people, they are excused from the jury, right. Whereas, often in in our peer review process, we are reviewing people that not only we know them, they're our partners, and as we discuss these things, they're in the room with us. And it would be I think, in an ideal world, it wouldn't matter and we would look at these cases, absent, who were the caregivers in that situation, but it's really hard to do, whether it's conscious or subconscious, when you know that the person you're reviewing is, is your partner, and you know, you know everything about that person and you know, you also know what kind of stressors they're under and the, some of the mitigating factors, and frankly, you also know that they're going to be reviewing you. And it's the old saying people glass houses shouldn't throw stones comes up a lot in peer review, right? It's, it's, you know that you you're going to have a complication, and you're going to be in that seat at some point. And so all of these things, color that process and make it so that it's not exactly what it's intended to be, which is this very unbiased review with the idea of getting to the truth. And in getting to the truth, that you may be fined, systematic for decision making elements that could have been done differently so that you can not have that happen again.

     

    Jerrod Bailey  10:45

    Right, so that's kind of like this one area of peer review that sort of gets you know, critiqued, is the data itself good, just because of how, what we're asking humans to do that, no, unlike each other, right. And, and it's not to say that, if they didn't know, like each other that bad things would happen, it just mean that you get to remove that element out of that, that interaction in so that everyone can feel a little bit less sort of, sort of biased and really just look at the facts at hand. And, and hopefully that helps things get through, I think another thing that we, that we see in peer review is it we'll see, we'll have a situation where the specialist is being reviewed by someone who's not at the same specialty, or have the same experience level or not even by if it's a doctor by another physician, right, it might be a team of nurses that are reviewing physician so that you also have the problem of when I'm trying to do these reviews internally, and I don't have the equivalent resources, it's really hard for me to get those types of reviews done as well.

     

    Dr. Ara Feinstein  11:58

    Absolutely. And I mean, think about the smaller facilities, for instance, that might only have one of that specialists, which can you sorry, think about that that particular smaller community hospital that might only just have one of somebody who reviews that person and gives them a fair shake, if they're, if they're not in that same specialty, you can even think of a big practice, but big orthopedic practice, but they only have one hand surgeon. So who reviews the hand surgeon Right. And, and so I think that's also problematic that you really, when you're in these situations, and you're the person being reviewed, which I can just tell you from experiences, is pretty anxiety producing. And one of the things that you, I think, really would hope for is that the person that's reviewing your case really understands the details of the clinical scenario that's involved. Right, and that's hard to do unless you're in that specialty.

     

     Jerrod Bailey  13:18

    Yeah, that's right. And I just talked this week to, to a position that actually wrote a big paper on peer review itself. And it was the genesis of it was, he was peer reviewed by a by a nurse. And it was an unfavorable review. It and in he will say is based on that she just didn't understand the medicine as, as another physician in his, in his specialty would understand it. And so it all ended up fine. But he had to go through this whole process, beep just because the reviewer was not, was not the right person to do it.
     

    Right. Okay, so that's interesting, right? So we have this, this problem of these kind of two problems, where we have this sort of embedded bias with certain individuals that are reviewing each other. And then we have this disconnect between what I'll just say, as unqualified reviewers are reviewing an individual, and that is inherently the problem of kind of only doing our reviews within this finite pool of, of our employed physicians or employee medical staff.

     

    So when I think of what healthcare is going to be in 10 years or 20 years, I'm looking at other industries, what they're doing. I'm looking at industries that create this, you gave me this term but democratized access to experience right to individuals with certain very specific backgrounds that if you create an easy way to access them, then you, you sort of unfetter and you democratize disability to take really complicated in really sort of experience driven areas of practice in be able to do just do more faster, and get better quality of insights from the, from the people that that are involved.

     

    So you look at other industries that are really good at this. And they've built marketplaces, and they've built, they built platforms, where you think of like, like, the GL G's of the world, right? Where they go, and they find the experts and all the different areas of life, and then they make those experts available to venture capital and private equity and hedge funds, who when it comes down to making a profit, they're very interested in talking to people with the right backgrounds, there is no interest in I want I want biased results of any kind, it's I need to get to the individuals with the deepest skill sets as soon as possible and really get to bedrock in terms of what truth is. So you have these industries like that, that do it really, really well. And it's that profit motive that sort of drives this very, like pragmatic like how it gets truth in it.

     

    I think that we can learn some things from that and then we can start to apply it and I think we can project ourselves forward in 20 years. And imagine that medical specialty is a little bit more democratized.

     

    Jerrod Bailey  21:06

    Yeah, yeah are we heading in that direction?

     

    Dr. Ara Feinstein  21:12

    So the fact of the matter is that medical expertise is really concentrated in certain geographies. And there's a huge opportunity to bring that expertise. Outside of the traditional brick and mortar confines that we've seen in healthcare. I think you're starting to see that a little bit with telehealth, right. I mean, you're seeing providers a little bit more able to see patients outside their geography. But in terms of expertise, I don't even think we've come close to scratching the surface of how do we give people that need access to experts, not necessarily for direct clinical care, but for everything else? That that absolutely has the power to improve healthcare quality? And, yeah,

     

    Jerrod Bailey  22:11

    yeah, I think that's right. And I mean, you look at you know, there's, there's a lot of money being spent by a lot of companies to find their way to medical specialists and get some sort of insight from them, right? very inefficient, sort of marketplaces out there. And I meet a lot of doctors who were burned out right now, and they're trying to rebalance their lives, and they're trying to do other things in they've accumulated a lot of experience that is really hard to duplicate, and it's hard to find anywhere else. And there's real value locked in that. And in whether it's another hospital system that could benefit from that, or it's a company that needs that individual to look at a case I think there's a ton of opportunity there just working with some hospitals that we work with some of them are, like small clinics, and you might be in the middle of nowhere, and, and you really need to access someone with some real experience, right as another as another physician.

     

    And in fine in figuring out how to do that, like there's in by the way, there's so many physicians out there that want to be reached, or so many specialists that want to be able to provide that expertise. In So here, you have, like, demand on both sides, but you just you don't have in there's certain practical things standing in the way of that, like, how do you find that person? And, and how do you create that interaction in a way that sort of mutually beneficial.

     

    And then there's other things that stand in the way of that, like, you still have in some systems, you have, like non-compete clauses, and you have things that are maybe even preventing doctors from doing certain types of work. So you've got some of those things in place. You've got also how does the insurance of all of this stuff work? Right? Do you need insurance to do these things? Where does liability come in, with these different types of things, and you're seeing some innovative new things come out to enable that sort of thing. 

     

    So I think as you see some of these little innovations occur, you're going to see a flattening of the world, and you're going to see more and more opportunity for specialists to really kind of be accessible to groups that can really use them. And I think there's you've told me this really is there's value in extending your influence beyond your geographical balance, right?

     

    Dr. Ara Feinstein  24:44

    Absolutely. Yeah. I mean, I think, I mean, when you think about an expert and when we say expert, I mean, I think obviously, there's varying definitions of an expert, but when it comes to a particular claim, Good practice. For me, that's somebody that has been at it for a while and gained some real experience. And deep subject matter knowledge as it relates to that clinical area of practice, they've probably been a busy practitioner in a busy place for a significant amount of years seven to 10 years, at least, with good outcomes, right? good track record, from a malpractice standpoint, good standing in their community, high level of referrals, right? It's hard to be busy and productive. If you don't have a good referral base, which means that over time, you build up the reputation to have good outcomes. So I think there, those are a few of the factors that go into being an expert. But my, the point I was trying to get to is that if you have become that person, right, you have invested, first of all, a huge amount of money the average physician is graduating with a couple $100,000 in debt, or more. And then you had this huge opportunity cost while you were earning that knowledge. And so I think physicians are really excited to find ways to leverage and even monetize that knowledge beyond their traditional clinical roles.

     

    Jerrod Bailey  26:31

    You know, yeah, it's funny, in the in the tech world, you saw over the last couple of decades, these marketplaces pop up where used to be I need to find a full stack, senior developer. And in to do that, I would start networking, and I'd start asking around, and I would, I would try to find someone out there that was available that I could hire as this full stack developer. And then over a couple of decades had these marketplaces pop up, where I can go log in, I can punch in a search. And I can find some of the best full stack developers of specific technologies that I'm looking for specific areas of the country or the world. And it's delightful. And it fills this need on both sides. And you see these developers just able to create all kinds of income on top of what they're doing, right. You see here, a lot of moonlighting in the software development world. I know software developers that have made really, really great careers, just taking site work, just because they're these more efficient marketplaces that are popped up that have enabled him to do that. And when you see that happening in the in the software world, it's not a hard leap to imagine that happening in healthcare as well. And I think once you see that, you'll start to see a lot more efficiency, we're talking about utilization and talking about efficiency and use of, of the talent that's out there. I think the industry 2010 20 years from now is going to be much more sort of fluid the way that other industries have been.

     

    Dr. Ara Feinstein  28:13

    Yeah, I agree. I mean, I think I think there are those hurdles that you're talking about, but I, but I don't think that they're insurmountable. Right. I mean, I think if that marketplace can be robust on both sides. And the those transactions are, are easy, I think you're going to see that, to your point really explode. I mean, the thing that I've been really surprised by, in working with you, and Medplace is that the, the physician demand side is incredible. I mean, the number of physicians that want to do this type of work, is it, it really has been almost overwhelming to have to turn away physicians that want to do the work, because typically, if you're looking at trying to get physicians to do anything outside of their normal clinical role we all get these emails about surveys or expert work or like lots of different opportunities that sort of come your way. But usually, you just delete them because it's either too onerous or too complicated, or it doesn't pay enough or

     

    Jerrod Bailey  29:38

    you don't even know if you'll get paid.

     

    Dr. Ara Feinstein  29:41

    Or you don't even know if you're going to get paid. And so, I think what you're saying about the efficiency of that marketplace being a real Kickstarter, I think that's true.

     

    Jerrod Bailey  29:55

    Yeah. You know, I think something else that gets in the way, kind of coming back to peer reviews, and it gets in the way of doing like, when you talk about doing an independent peer review, doing it externally, right getting outside of your employee group to get peer reviews done. There's really philosophical differences out there. And in the, it's a whole spectrum right, there's, there's hospitals that purposefully do more external peer reviews than they even need to just because they're there, they are already aware of bias, and they want to account for it. And they want to, they want to build a system that they feel really does inject real data back into their, into their systems. And often you see that accompanied with a culture of not being not castigating, right mistakes are going to happen in the course of practicing medicine. And you see that come with a culture of you don't you're not getting shamed. And, and I've seen really strong cultures where it's like, hey, our peer review process is robust, and it's meant to be that way. And we all feel better about ourselves as being part of it.

     

    And then you see hospitals on the other end that it's a punitive culture, and so there's, there's cultural things that get in the way. But there's also this this, like I don't know that I want to like dirty air, my dirty laundry out there, I don't want to know, I'm not sure that we should let this outside of our four walls.

     

    And, I think that when you look at modern technology, and modern systems and other marketplaces out there, they've already accounted for those types of things, right? You can have things be completely anonymous, and it's kind of a different world. There's certain challenges or whatever with healthcare, but I think they're not insurmountable.

     

    But I'd tell you, we just had one of our clients was doing an independent peer review, and they were really the risk team who's actually led by a physician, right, which is sort of unusual, right? Actual MD, leading the risk team. And looking at the history of reviews, and if they get them done externally, they get them done through like law firms, which sort of come with their own bias. And in really just wanting to talk to actual physicians, actually, with clinical experience, that have done this, that are currently in medicine, that understand the realities of boots on the ground, and, and they just did their first review a couple of weeks ago, and it was, it was, it was great. It was there's no bias involved, it was very this is, this is what this is, this is the good, the bad, the ugly, but this is what the medicine is, and this is here's the citations that that we all want to look at, and in the data to sort of backup this decision, and it was such a great conversation between the risk department in this in this outside clinician, that in a sort of exactly what everyone wanted, even the provider that was being reviewed, right, being able to say, “Wow, this is somebody with the background that I actually feel proud to be reviewed by and I would hope I would be able to do this for another colleague of mine”.

     

    And I think that's where you land is when I talk to doctors, they're, they're really so interested in you can I mean, you can tell me from a from a physician's perspective, but helping another doctor, in someone that you recognize, as appeared? What does that like?

     

    Dr. Ara Feinstein  33:31

    Yeah, I mean, for me, one of the things that I always talk about when I get an opportunity to talk to some of the other Medplace experts, or even when I'm talking to my own residents about this whole peer review process or the m&m, and I think that one of the things that you have to do always is approach any case you're reviewing with empathy, right? You got to approach the case with empathy for the patient who probably had something terrible happen, and then empathy for the provider, right, that that was part of that care.

     

    And so the first thing I do when I review a case is to like, take a deep breath and think about, wow, like, what was what must that have been like to realize that you kind of common bile duct or that you didn't recognize that somebody was bleeding and they died? And I always just take that second. And I think that what that does is it helps you to get to this place of like, not finger pointing, not blaming, but just saying what really went wrong here and how could it have been prevented? And I think that's an approach that I think is really important, because what you would want, like you said on the reverse is that same level of empathy towards you and your care and towards your patient and that somebody was really looking at what happened with an eye towards getting to the root of the problem and learning something rather than finger pointing.

     

    But to go back to what you were saying about some of the barriers that these institutions have, and why they want to keep these things internal, right, and why they want to keep the system the way it is. I mean, I think, I think the other thing that you have to call out is, is cost. And the way a lot of these peer review systems work right now is that like, for me, if I get a peer review, then I just supposed to do it, it's part of my job, but I think, when you look at that globally, and if that's how all peer reviews are done, and if you pay, if you pay nothing for something than that, you get what you pay for, and that's why your reviews take so long, because if it's like if I have 8 million things to do, and if this is thing 8,000,001. And a lot of the other things I'm doing, I'm being compensated for, but I'm not being compensated for that thing, human nature is that it will fall down the priority list, right. And if I'm not being compensated for the amount of time and effort that I can put towards it, there's a calculus there.

     

    And so, I think there are not enough hours in the day for most physicians, and so if you just pile peer review on top of it, the quality of what you're going to get, may not be what you want. And that's not to say that we don't do a good job on things because we're not paid for it. But it's just a question of how much time and energy can you devote to something. And then, and then the other thing, which is really key to is that the manner in which that's conducted if it if, if I only have an hour to devote to this, and 35 minutes of it is like digging through charts and medical records and dealing with some peer review system, which some places have, which is archaic, and there's a lot of button clicking, and whatever, well, then, of the time that I could have spent providing better insights I have now wasted on this terrible system of the way the case has been delivered to me and the way I'm supposed to deliver the information back.

     

    Jerrod Bailey  37:45

    Sorry, you're still there? Can you hear me? Yeah, I can hear you. Sorry, I think one of us one of us dropped, it might have been me, or at least temporarily. So well, so it sounds like, it sounds like we're all especially you all that are out there practicing medicine are asked to be doing more and more. Oftentimes, that involves paperwork, and administrative things that are hard. And then you have peer review that piles on top of that, then you're asked to do take that seriously, I mean, you have to do that also, with this, like this, like threat of politics behind it, that you have to navigate emotionally, right and try to make decisions around. And in here we are humans inside of the system trying to do good by each other. And it just seems like the system is sort of set up to, to not really that's where the frustration is, I hear it a lot.

    And you know, I don't know anybody in this system that's necessarily happy with it. But hopefully, this gives people something to think about. And as they're looking out, they're looking and sort of being self introspective about their own peer review program and other programs that they're running, to maybe try to think of different ways to do it. And imagine and start to build towards what medicine is going to look like in 20 years, let's, let's start building it now. And let's start experimenting now and seeing if we can not only get better data out, but also relieve the burden on our physicians in multiple tiers of burden there. You know, and then see if we can't find our way through it with just a little bit sort of a 2.0 kind of mentality on you know, how we're thinking about our quality and our delivery or care.

     

    Dr. Ara Feinstein  39:39

    Well, that's ripe for innovation. I mean, I imagine in your, in your work in this area, as you've talked to hospital administrators that might have a 500-case backlog of peer reviews or as they talk to doctors that are both on the giving and receiving end of these reviews. I don't imagine you're running into a whole bunch of people that are like, no, it's working awesome. Like I don't see any way that you can make this better. This is going great. It really does seem like an area that there. There could be a lot of technology and process applied that could make this better for everybody. Yeah,

     

    Jerrod Bailey  40:18

    I think that's right. Well, I hope that's right. That's certainly the mission that we're on. And I appreciate you for giving us guidance along the way. But Dr. Feinstein era, Thanks for Thanks for joining me today. Appreciate the time as always.

     

    Dr. Ara Feinstein  40:33

    Yeah, always great to you know, you and I are both always running and so even just having a few minutes to just talk and think through some of these ideas. It's a lot of fun.

     

    Jerrod Bailey  40:45

    Great, well, it's all of you listening. Thank you again for listening to the reimagining healthcare podcast. Appreciate you joining us, Dr. Feinstein. And again, if anyone has any interest in being speaker, just email us at speakers@medplace.com you can find Dr. Feinstein on LinkedIn, it's probably a good way to find you as in any other ways that people should try to connect with you.

     

    Dr. Ara Feinstein  41:09

    That's probably the best one that's where I try to connect with people the most so yeah, I think that's probably your best bet.

     

    Jerrod Bailey  41:16

    I promise everyone you'll be entertained following era in his exploits from the clinic and onward. He's he really knows how to bring empathy and humanity to you know, what, what can be pretty difficult job sometimes. So appreciate you doing that, that hard work, or and in other than that, thanks. Thanks again for joining us, and we'll talk to you guys all soon. All right, thanks, Jerrod.

In this episode, Dr. Ara Feinstein speaks with Jerrod and provides insight into the peer review process. Dr. Feinstein also discusses the need for unbiased reviews, the current status of specialist/expertise marketplaces, and the future of the healthcare industry.

Dr. Ara Feinstein

Guest - Dr. Ara Feinstein

Trauma Surgeon, Banner Health

Dr. Feinstein is an award-winning trauma surgeon at Banner Health. Feinstein holds a master’s degree in public health, with leadership experience in healthcare's clinical and administrative functions.

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