บทถอดความฉบับเต็มของ 20 - Dr. Patrick Pulliam - Systemic Thinking and Leading the GA AAP

come home. Good thing good thing you're you were a urologist. This is true. ⁓ wow, okay. I did not know so I live five houses from my parents. So I know what that's like. ⁓ wasn't the plan, but it worked out. That's amazing. And so speaker-0: This is the first jazz song I ever learned, by the way. Michael pick it up and I can't tell you the name of it. Straight. Alto Alto. And some ⁓ piano. All right. And a pet orchestra, I'll do a little more. I'm not used to but that's that was a lifetime ago. So But I was in the Redcart Marching Band in PA. Yeah. And they have a four or five hundred play alumni band that show up every year and let us they let us play. speaker-1: Right. ⁓ I don't know if the mic will pick it up. So you play piano? ⁓ you play sacks. Straight sacks? Do you still play? Yeah, yeah, for real. That's a speaker-0: So when I have a chance, I go. Yeah, it's great. So I started the practice, was by myself for a while. Yep. Eventually hired a nurse practitioner and then all the pediatricians left our hospital who were seeing newborns. speaker-1: Just ⁓ at once or speaker-0: 'cause of Epic. Okay. And ⁓ B Mont Healthcare took over the hospital. Okay. And they f ⁓ may told everyone they had to do baby friendly requirements. Yep. ⁓ and then pretty much all twenty five of them left and left as five or six of us. Anyway, we ended up with a contract to provide newborn kids at the hospital. Okay. And then the other five or six left and it was really just me. speaker-1: ⁓ Wow. So So they wrote you a big fat check to stay. speaker-0: Yeah, they pay us every month to say it's okay. Pay us to take call. And we have to recruit all the newborns. And we get to bill for the newborns. speaker-1: So you you built the bridge straight to your front door, so speaker-0: So yes. And we were already doing lactation. I was already doing breastfeeding. Yeah. ⁓ and it just uptown nicely with that. And so I I wrote all these books and handouts and beautiful folders to hand on new moms and stuff about about our practice and about taking care their baby and Yeah, yeah. So now now I have four or five nurse practitioners. speaker-1: Good for you. Do you think you could grow? Yeah. speaker-0: We've ⁓ we could. Finding enough with good staff to fit our culture is difficult sometimes. we've we moved once and Medica door to Medicaid say you're a different you're not a board certified pediatrician anymore. You won't we won't pay you the enhanced rates anymore and that was horrible. speaker-1: I I don't make the connection. You moved and so then speaker-0: For medica for the enhanced rates after the ACA thing stuff, if you were new to Georgia you couldn't if you didn't attest at the right time, you were out of luck. And the doctors who failed to attest and so they get paid the old rates. And then if you were new to Georgia, the program was over. Right. And so when I moved across the street, I was new to Georgia. speaker-1: That's insane. Yeah, yeah, yeah. But though though totally believable. speaker-0: I went to my legislators and said this is insane and they actually fixed it. speaker-1: Good for you. And that's why you're the incoming president of the job. speaker-0: But then we exp moved to a different building. Then we ex maybe knocked out a wall, expanded to the to the rest of the building. Okay. And we're out of room now for exam rooms and stuff. Yeah. Ten. Yeah. Although we do have we have a conference room and we have a we built a classroom for community classes and stuff. No. speaker-1: I mean Samram's You're tight. speaker-0: So we did the kids plus pediatrics kind of thing with the community room and that kind of thing. Don't get me started. But ⁓ anyway, we could turn that into a newborn area and that kind of thing. Okay. speaker-1: I miss I missed that print. Yeah, don't get me started. I'm just curious, how many newborns do you get a month? speaker-0: Well, a lot of them follow up with us 'cause they can't leave the hospital anymore until they have a identified source for promo a recommendation. And I get to make the rules now. So we don't we won't send you home until you have a doctor. Okay. And so a lot of ⁓ will come follow up with us and then pick pick a different doctor and stuff. Okay. But we must see five a day. Probably three, two, three. speaker-1: Whoa, how many of those do you keep? Dang. And you're not you and you with ten exam rooms. You needed a second office. Yeah. speaker-0: And we'll see ⁓ through college, so speaker-1: Wow. Okay. ⁓ and and and I think I now understand why you asked me about how to calculate the the ⁓ up optimum of panel size for a pediatrician. I don't now you just filled in a that's kinda funny. speaker-0: Well actually we're trying to solve the workforce issue in Georgia in Georgia. Yes. speaker-1: But but by the way by the way. Okay. Okay, that's amazing. All right. In my experience you seem to be someone who's willing to raise a hand and do something, which is something I I always admire when I see the the people are willing to volunteer or serve. And so you are now incoming as a what what do you have? You got a two weeks left? Two weeks and th and then you become vet president. ⁓ I asked you this yesterday. speaker-0: Two weeks of as Vice President. speaker-1: And you gave me an answer I didn't expect, but ⁓ what are you what are you hoping to achieve or what do you predict for Georgia ⁓ over the next two years? Nope. I mean Yeah, let's start there. Yeah, what are you trying to change? If you could wave a magic wand, what would you speaker-0: You want a different one today? Sure. What am I trying to change? For the chapter or for the practic pediatrics in Georgia? speaker-1: Pediatrics in Georgia first. speaker-0: All right, here's the big picture. All right. I think that primary care in general and pediatrics in particular is in trouble. Yeah. I think that it hits Georgia a little later than some other states. Okay. ⁓ I think that there were people raising the

flags and warning signs now, including the AP, which is the AP's made a hundred and eighty degree turnaround. Mm-hmm. Are thinking that this is speaker-1: I agree with you. speaker-0: the canary in the coal mine, and I think the canary in the coal mine was ten years ago and what's happening now is the chickens coming home to roost. Okay. And if we don't change things fast and quickly and systemically, it's not gonna get better, it's gonna get worse. And that's that's workforce issues, that the margin's completely gone in pediatrics. And so speaker-1: I think that's regional. speaker-0: Well. speaker-1: Mean but but it it doesn't matter what I think, you're here in Georgia. Well you know that speaker-0: the I think in general it's difficult to stay independent and be profit. I mean my practice is profitable, but it's speaker-1: Yeah, it takes hustle. Well there are definitely some parts of the country where the systems have squished everything out. And that doesn't benefit anyone except for the systems. speaker-0: Yeah, I think that's coming for most places, whether it's hospital systems or biz corporations or private equity. Yep. speaker-1: It is coming from all sides, but what I tell you what I see, because I don't disagree with you. There are parts of parts of this country, it sh and a lot certainly the urban areas and Atlanta's a good example, but Boston, New York, Chicago, LA, San Francisco, you have to belong to a system. And that usually also means you all you're on epic, whether you like it or not. None of which benefits the patients at all. And usually is pretty detrimental to the physicians. But what we're seeing is PCC, we had more solo startups in 2020, 21, 22 than we had in the first 15 years of this century. And so what I what I think is happening is so many of these people are getting in the systems and saying, ⁓ this is just this is nonsense. And they leave. Now the I will tell you if you're an EHR vendor. speaker-0: Fantastic. speaker-1: It's tricky because and and I know OP suffers with this, they have to, and who doesn't suffer is Epic and Athena and so forth. It turns our ten doctor clients into two doctor clients, which is challenging because we have a ten doctor client that sells to PE or sells to the hospital, and then a year later two of them come out, and that's a that's a rough business model. and so we find ourselves chasing that, but and to be honest. If I could rewind ten years, I would remodel REHR to focus on high Medicaid small practices. Because there's an an invisible army of them. And and the problem is though that those practices require a lot of care and feeding. They're harder to do. Most of them. Not all of them, but most of them. You know, practice your size with a owner who has his act together, that's easy. Like be easy to ⁓ work with your practice, but a high volume practice that depends on making sure that they jump through exactly this hoop so they get their payment and then they change the rules and then their staff is all turned over and that's it's expensive for everyone. speaker-0: I haven't really thought about it from the perspective of trading out ten p doctor practices for two doctor practices. speaker-1: Yeah, but you don't get five two doctor practices. Right. You get two one or two one or two doctor practices. ⁓ but I say all that, the same thing happened twenty, twenty five years ago. This pendulum swings. We'll see what happens this time around. speaker-0: No. Yeah, you know, my my big thing and I hope our big thing is that you don't have healthy children, which has to be the North Star of the Academy or the org chapters or pediatricians without healthy pediatricians. And adequate pediatricians. Right. So totally agree. You can't have healthy healthy children. ⁓ speaker-1: It's impossible. But what they say? That those exact words. speaker-0: Well about a healthy, adequate workforce and ecosystem. And you know, you mentioned people working for systems and leaving. But it's not just burnout, it's moral distress and moral injury from when you lose agency and you lose autonomy. speaker-1: Autonomy and independence is the thing that is the root of burn. speaker-0: And right. So you can't you know, it's a it's a I don't know, cliche that you you read all these medical student or resident applications, which I used to do and you know, I wanna went to medicine, I wanna go to medicine to help people. Right. But it's not not true. Like the vast majority of people go into medicine I I they w generally believe that's to help people, especially peop ⁓ pediatrics. Of course. They want to help people. I don't speaker-1: General. became a pediatrician to make money. That's the dumbest or they were dumb. Right. You you should make money and you should be able to make money, but that is not what motivates pediatricians. Never has. So speaker-0: They were misinformed. When you work for a system that puts business interests first and not your patients. speaker-1: You are you are then working for someone else and not for the kids and that erases the entire reason you spent all that time. speaker-0: And that causes not burnout, that causes moral distress and moral injury. speaker-1: Yeah. When I read the book Drive by I think it's Daniel Pink, that w hit home for me because he said there are three things that didn't want Yeah, you know this 'cause we've talked about it, but the purpose, you have massive purpose as a pediatrician. You have a mission every day when you get and I'm what purpose is better than taking care of kids? I mean, like that's Yeah, it it's it's huge. Like you are you well, I said speaker-0: Exciting lot. David Allen says, you we're we're literally saving life. speaker-1: You you're saving lives incrementally every day. I've always believed that. And then so it's independence. it's mastery. So I think as pediatricians, I mean you're in a constant learning profession. You learned more between March 2020 and March 2021 than you had

in the previous five. Like you you are constantly ⁓ learning, improving, getting better. So you have two of the three things, and the thing that you That so many people are losing is the autonomy. And that and when I read the book, all of a sudden I'm like, that's that's the problem. You see how you can help the kids, but you're not allowed to do it. You can't and speaker-0: And you're part of a system now. You're complicit in it. speaker-1: Right, you like gifts, you've contributed to the problem that you want to fix. Right. I agree with you. That is the heart of it. I back out a little bit further and I try to think, can you name a system or a collective of people that doesn't actually serve itself first? Because I was thinking about this. I'm like, okay, every university in the country, every hospital. speaker-0: Right. speaker-1: The Boy Scouts, the this hotel chain, they all eventually a collection of people who serve a mission, eventually it gets large enough where the the mission becomes primarily the vibe the viability of that organization. No, and so I don't think the people in the hospital are bad, but I think the hospital is sociopathic. Or like tell me I'm wrong. The hospital doesn't have feelings. The people do. speaker-0: Well, a lot of them are trying to survive. Right. The w the first book written on moral injury in healthcare, it's all these stories and ⁓ inevitably they involve a health system taking over a practice or taking over a hospital and that kind of thing and stuff. And what happens? And the Glockenflecken's talking about Seattle and Virginia now. Yeah. ⁓ in the past few months. And what happens? Sh she was somewhat critical of the hospitals because the hospitals are suffering a lot of hospitals are community hospitals. Yeah. S are struggling to Loss of margin and struggling to survive. And right. And some of their decisions are made just just to survive. speaker-1: I say this very naively, or at least I'm oversimplifying. I know that when I say this. But I know what it takes to run a pediatric practice, which if it's admittedly as far removed from a hospital as anything can be in our in our space. But I look at it and like you can have margin and you can pay people fairly and you can ⁓ make the patients healthy. I see as you climb the ladder, like as you as you if you went from your practice to now it's ten practices to now you're opening a ch a children's hospital. I think the biggest problem is you end up when you scale, you have to put so much stuff in the middle to scale. The management of the organization starts to override the thing it actually does. Right. And so I I I just think so many human endeavors aren't designed to scale. speaker-0: And it's very expensive. Yeah, this there's a bigger picture to that, yeah. Businesses suffer the same. Right. speaker-1: Yeah, I I mean you you you are in the problem. I think there are some things that can scale. ⁓ think of something like farming. Farming scales, but at cost

that we don't see. We h hide it. Healthcare scales, but the cost a lot of the time we don't see it until we're in it. I just think pediatricians are in the relationship business and relationships don't scale. I don't think you can suddenly be more efficient in your relationships and suddenly have just see twice as many kids effectively. It just doesn't and I I almost feel like the way for the hospitals to survive is to put themselves out of business. Break up into ten pieces. Trim your stuff. I I'm I don't know how this would work. I'm just saying the the hospitals get so big, but they they can no longer make a good decision. There's no decision they can make that doesn't cut off its own foot. This is the right choice that this part of the body It has to harm the other part of the body. speaker-0: I think they're doing it though for the same reasons that practices are doing it. As in the the evil empires, the insurance companies have taken so much of the ⁓ well at the money out of the system at this the hospital has to consolidate and grow the hospital has to grow to survive. Right. Just like speaker-1: Point. Right, they have to chase it. It's all h healthcare inflation. speaker-0: And have to compete with the other ones for the for the market. speaker-1: Just it it doesn't improve anything. speaker-0: They're trying to survive. So I feel for them. And you know, it's the same reason that Sandy Chung and Christy Sosia ⁓ the people are forming supergroups, you know, to Well, they're gonna have layers of management now and layers of speaker-1: To protect ⁓ And it's not the same. ⁓ well, Neil the thing I f think is at the end, or whatever, not the end, but at some point if the system collapses, pediatricians are one of the few specialties who will survive and thrive. The and the reason being, very simply, do the math. You can pr I bet you can probably do it in your head. If you add up all the dollars that you generated for revenue last year and divide it by patients, it's like fifty bucks a month. That's all that your patients pay you. Now they have speaker-0: It's gonna be it. speaker-1: They have ⁓ insurance premiums that are fifteen, twenty thousand, right? Which is to your point. But you could convert to a cash business tomorrow. I mean take you a couple of days, and you would live. And all of your kids would go to school and you'd ha pay your mortgage. I don't think any of your surgeons can do that. Like you know what I mean? The neurologist is in trouble, you know. speaker-0: Dependent on other things. speaker-1: So that's why I think you do all right. The only I will tell you that the one thing that does scare me for our work is the decline of the birth rate. Yes. And that's a con as long as people are having babies, it's a growth business. And with the economy and some of the behavior that you see, I mean and you know this, a lot of those kids are delaying having children. That I I'm keeping my eye on that birth rates is speaker-0: Yes. speaker-1: A real thing. speaker-0: Yeah. All over the world. Yep. And Georgia is a net influx state. So people are moving to Georgia. Right. So that helps a little bit. speaker-1: Vermont is not. Okay. Vermont is not. speaker-0: Still, it's a it's a concern. Yeah. ⁓ I do a lot I'm doing a lot of workforce research and workforce work and child population is projected to decrease in Georgia for the next ten, fifteen years and it's supposed to start going up again. speaker-1: Well, it what will be interesting is to see as the pediatric workforce declines, if Adam Smith had any anything to say about it, the fewer pediatricians means your revenue should go up. Should. But right now it has no like that's the part that I don't I'm having a hard time I know why it's happening, 'cause it is the evil empires. But with fewer pediatricians, you should be more in demand and they don't seem to care. speaker-0: Theoretically at some point the insurance companies would have to increase payment in order to have pediatricians. But they won't on their panels. But since pediatricians depend on them to survive to get paid anything, it would be a difficult bring about weight to break their contract with the missioners. Say I'm gonna leave your That's why the pediatricians no doctors don't do it, right? Yeah. I'm gonna leave in thirty days if you don't speaker-1: We'll do it. It will it will have it in the year. Not enough of them do it. I d you I mean you know I try to tell people to do it all the time. speaker-0: Scared to do speaker-1: You know what? This is something I learned from Lynn Kramer. Every year you run a report, rank all your payers, and cut the bottom one. And the the first time it's scary, by year five, especi by year five, by the way, the people you cut off, they're back because they cut they come back with a deal that they that they never would have given you. But they need to feel the insurance companies are sociopathic and they don't feel pain. So it doesn't matter what the right thing to do is, it doesn't matter how compelling your letter was, doesn't matter how wrong they are or right you are, it doesn't that doesn't pay the shareholder dividends. So they don't care. They don't care. I've never met anyone who cares. It doesn't Anyway speaker-0: I'm generally not in favor of a lot of government regulation of things, except within certain bounds, you know, that it's necessary for some things. But they are sociopathic. They're not serving a social good. speaker-1: No. And they they they don't contribute at all. It's only parasitic. speaker-0: And so should somebody make that stop? I don't know. speaker-1: Well the the qu Yeah. Well let's be let's be clear, healthcare is not capitalistic. It's not because cap proper capitalism requires transparency and the people making decisions about their own healthcare, the patients do not have any insight into act the actual financial implications of what they're doing, and nobody has insight into what the

payers are doing. Correct. If anyway, boy, we could talk about this for too long. All right, so some other questions. speaker-0: Capitalistic system isn't issues. That's true. speaker-1: As a pediatrician, we we just highlighted a couple things that are making us anxious. Birth rate, our friends. What are you looking forward to though? First as a pediatrician, then as chapter president. What are you looking forward to? What excites you? speaker-0: Well, pediatrics is always advancing. Mm-hmm. There's always new challenges. Yeah. Like the effect of social media on kids. But then that's a chance to make a difference and educate parents and that and develop those relationships. So I'm excited to keep doing that every day. Okay. I'm excited to help other people do it, whether it's my nurse practitioners. Yep. Or whether it's as chapter president that we empower pediatricians in the state to be able to do that. ⁓ So that's exciting. Okay. Make a difference in the life of a child and a family. Yeah, they can last generations and get paid to do it. So what excites me about chapter president is that helping pediatricians do that. Mm-hmm. And I've worked really hard to develop a conceptual framework for the modern pediatric medical society and medical societies in general. Okay. Pediatrics in particular. speaker-1: It there's no better reason to get out of bed. speaker-0: In state chapters, why they exist, right, and what they do. And what's this value proposition right now? And what's the future of pediatrics and how does that chapter fit into that? Okay. Develop a conceptual framework for the chapter. Sure. Then taking that and then restructuring the chapter for ⁓ impact in child health and in policy, but also in empowering pediatricians to thrive. So that children thrive. speaker-1: Some of which barely do. You share this at some point? All right. I'm now I'm interested. When are you gonna unveil this speaker-0: So ⁓ you know picture this I can do this in my exam room or in my practice, but now I can do it at a still high scale. Yeah. So that that really that really excites me. speaker-1: Okay. That was a good answer. Alright, my last question. You ready? No, it's easy. If you could go back, it's not easy. Actually, this is the one that people struggle. speaker-0: No. I know the answer to this question. Yeah. I know and I I've heard you ask it but I just know what my answer is. speaker-1: ⁓ yes did you prepare? Okay. So if you could go back and give yourself advice, what would it be? speaker-0: I didn't network or unite with other pediatricians until very recently. And it's not really like what it's not what you know, it's who you know, like you kinda like you're trying to get ahead. Yep. But by the same token, I could have had so much more enriched and rewarding career ⁓ and felt more supported and part of something. I had the national AEP, but I didn't have Georgia really. Yeah, even the national AP came a little later. Mm-hmm. But also the chance to

learn and grow from other people. Mm-hmm and to be inspired by them. You know, the pediatricians d disagree on certain issues and that kind of thing and stuff, but I've not yet met anybody, you know, if I disagree with them about something, who isn't doing it 'cause they think it's best for children. They're so committed and so dedicated to doing what's best for children. And I I could have used more of that early, ⁓ early on and I could have networked more and got to know more people and speaker-1: N now you're doing it like all the time. speaker-0: And and then hopefully contribute to that. Yeah. And I've started teaching that to my young adult children. Okay. The importance of going to things and networking and knowing people in your field and just like continuing education. Yeah. So I I regret that I didn't have those years. That's exactly what I would do to film. Right. No. I'm doing it now. speaker-1: Being the room. That's a good answer. But you're doing it Yep. And it's not that painful. speaker-0: No, it's not painful, it's wonderful. I just wish I had I wish I'd known it earlier. Right, right. speaker-1: I I struggle to network, but yet I do it incessantly. It's hard it's hard work for me, but it just happens. speaker-0: ⁓ I'm a I'm such an introvert, it's really hard work. speaker-1: Yeah. I'm well, we were talking about this yesterday and I and ⁓ who did I tell about it? ⁓ I was telling Katrina about what's the title of the book that you read? I gotta Me but better. I was like better than me. That was what I was that that's what I I was no, that can't be it 'cause that's bad grammar, maybe, but ⁓ anyway, yeah, so me but better and just the concept of ⁓ this is how I interpreted what you told me. The concept of basically having a game face. Or just to and knowing what persona you're gonna walk into in order to accomplish something in a space. And that's something I can identify with very much. speaker-0: It's it's a skill, learning skills that enable you to do what you need to do in that environment. speaker-1: I don't I don't ever worry about giving a talk because that's another person. Someone else holds all the anxiety about it or w if there is any, it just that is a persona. speaker-0: Yeah, it is kinda like that. It is like a somebody else on speaker-1: Yeah, it's someone over there. When I give a talk, I can be outside myself and hear myself talking and I'm listening to someone else. And so I don't I just I judge what he's saying and give him some feedback about well, you need to talk about this now. That is exactly how it happens. I s totally split. That sounds crazy, but that's the only way I could do it. Otherwise I I would be nervous. Who wants to stand up in front of a group of people? But anyway. Well, thank you very much. I appreciate it. Good luck your next two years. speaker-0: Huh. speaker-1: You're gonna revitalize AAP chapters all over the country, starting here. Gotta start somewhere. Start somewhere. I'll give you the list of the states you need to go to. Okay. ⁓ my word, there's some some that need some real help. It's amazing. All right. speaker-0: All right. speaker-1: Thank you for listening. More information can be found in our show notes. Production and editing by Chip Hart, Allie Squires, and Chris Forlio. Music by Challenger C. I'm Mark Herney.