Ehab Sharawy, MD & David Cook, MD – The Value of a “For All” Philosophy

Today on the Move to Value Podcast we have the first in a series of conversations between OneHealth Co-CEOs – Dr. Ehab Sharawy and Dr. David Cook, and CHESS Health Solutions President, Dr. Yates Lennon, about a “For All” philosophy of practicing medicine and the necessary connection between the patient and provider that benefits both.

Good afternoon, gentlemen. Welcome to the Move to Value Podcast. Let’s start and go back in time a bit. I would love for you to spend a little bit of time telling us what caused you to want to go into the medical field and to become physicians. Dr. Sharawy, let’s start with you.

Dr. Sharawy: So that could be a 20-minute conversation, or it could be a three hour conversation, but I’ll try and make it even smaller than that. You know, I came from a medical family. So, my dad immigrated here from Egypt on a Fulbright scholarship, and you know I was in the household and my mom was a dentist. And I had multiple family members that were in the medical field. So, I’m always drawn to it, you know, but never forced into it. And I think that’s really important. But I think when you start thinking about the medical field as your career, I think it’s really important I think it drove all of us, or most people, that do it, you got want to help people, you know. And I feel like that’s something that was stuck with me for a long time. So, I cannot remember the time where I didn’t think I was going to be a doctor. Even in the 5th grade, 6th grade, I can remember that. And it was really about that drive. You know, say look, you know, how can you make the biggest impact um in your life. And boy, I’ll tell you it’s an admirable thing to think about improving, being there for the people when they need you the most. And that’s in their healthcare. And then just to conclude on it, I never thought in the world I’d be an OBGYN. And Yates, you know, yeah, can relate to that. And so, seeing that ability to take care of people from literally the time that they’re in their childbearing years, even before that to the time that they’re in their twilight years, was very attractive to me to do that. And then really, I enjoyed the fact of being able to take care of people throughout their healthcare journey but also have the procedure type stuff that kind of excited me right at the time.

I think as a fellow OBGYN, it’s the perfect balance of primary care and surgery. So, Dr. Cook, what about you?

Dr. Cook: A little bit different background. I was the first on my dad’s side of the family to go to college. And, but yet, same, I do know Doctor Sharawy’s family, and they’re the same ilk. And Doctor Lennon, I can only imagine yours is as well. From as small as it was, I could remember them giving back to humanity, giving back to others. In fact, one of the things my dad once told me is the only thing you can take when you leave here is what you gave away while you were here and it’s better to give that to other people than take it yourself. And so, I learned from them about several things I believe that that brought me into medicine. One was this thirst for knowledge and understanding science and you know bettering myself that way. The other was how can you reduce suffering with those around you in multiple ways. And as I went into college, I was thinking should I be a veterinarian? Because I did do a lot of veterinarian work. I worked for a vet when I was a kid. And so, I went to NC State and as I was there, I met lots of unique individuals. But I had the privilege of spending a summer with a family physician in the mountains near Asheville for about two weeks. And it was it was life changing. I saw this family physician doing things, giving back to the community, taking care of people for 30 years, knowing multiple generations of individuals, and really making an impact not only on the individual that they had there, but the family and the community. And I really sat with that for a while I was at school, and I think by the time I was a Junior, I had decided that’s what I’m going to be.

Wow. That’s really very interesting and I already have better insight into some of the things I’ve heard you all say over the last few months. Let’s jump forward now and tell us a bit about the OneHealth story. Doctor Cook, I’ll start with you.

Dr. Cook: OK, we’ll even go back farther than that. So, the OneHealth story really started way back. This is my 30th year in practice as a family physician started in August of 1993. I was lucky enough back then to meet people like Don Berwick, Brett James, and others who are really conceptualizing a different kind of healthcare, more broadened healthcare, more holistic healthcare, preventative healthcare, cost reductive healthcare. And began to gravitate toward people like that. And I was lucky enough, and I’ll let Doctor Sharawy tell you the story because he tells it much better than me, in 2004 I got to meet Ehab and his group of OBGYNs. I had a small practice. Well not small but about 12 to 14 doctors at that time that we had collected together and were independent. Really trying to figure out how to do health care right. How do you take care of the individual? How do you take care of their family? How do you, as I used to say all the time, you know, if I’m in a room with a lot of different doctors and ministers, how do you put the patient in the middle or the individual in the middle and take your ego, and your wallet, your greed, and other things, put it outside, put compassion, passion, and science around the patient and do the right thing for the individual? And it was rare, I have to say this, it was rare at that time to meet others, I would say, as crazy as me thinking the way I thought, until one day I met Doctor Sharawy and his group who were moving into the neighborhood to become part of the hospital in Charlotte and around Huntersville. And it was at that moment in time, I knew there were other kindred spirits who really wanted to do the right thing. Almost always wanted to do the right thing, for the right reasons, in the right way. And I understand that sounds really altruistic, and sort of over the top, but it wasn’t, it’s what we were about. We’ve always been about the mission and the vision. I think we saw together, both as independent physicians, as part of a big practice physicians, as part of a big health system, the erosion of what we found sacred in healthcare, which was that doctor patient relationship, always putting first things first, the right thing first. Um, really looking at every angle about how to do things that were best for the patient. We pushed within systems that we were in to try to make a difference. Over the years, it definitely around 2010, 2013, 2014, were pivotal years for us. We had tried some real value work within the organization we were in. Organizing physicians to lower cost, improve quality, improve the human experience. We found it almost fighting against traffic, like going backward. We were not only looked at as if we were pariahs, but we really were within that system.

And Doctor Sharawy says this one thing, well I’m going to steal this from, he says, you know, we always heard it was good to be disrupters until you actually disrupt. And once you disrupt, you’re not looked at the same ever again. Even if it’s responsible disruption. And so, we were in the game to make a change and do things differently, and over the past decade, especially the past five years, we found ourselves needing to make a big difference. And at almost whatever cost it was to us personally, we needed to make a difference so that we could save what we felt like, save the profession for those that would follow both in OBGYN, Internal Medicine, Pediatrics, and Family Medicine.

We’re very unapologetically disruptive and very unapologetically primary care. And we felt like we needed to build another ship, so we set sail together here about four years ago, away from the other system, went independent for a while, and then we were able to partner with Advocate to do what we’re doing now, which we can talk about more in a minute. But I’ll toss it back over to Doctor Sharawy to let him give his take on that.

Dr. Sharawy: It was a cold December night, walking up hill both ways… I’m joking. So, you know our journeys were somewhat in parallel. You know, when you do your residency, you’re in this sacred place, you know, in residency when you’re training and you’re in a bubble. And I was fortunate enough to train at University of Florida with some of the best people to be in a bubble with that we’re talking about evidence-based medicine and talking about reduction in total cost of care before those words were even the sexy words that they are now, you know, in our field. And so, you came out ideally, and I think I’m speaking from many physicians right, you come out very idealistic, you know, when you come out of your residency training. Then you get into the real world. And I dropped right into Atlanta Georgia, which was maybe the epicenter of a lot of things that weren’t exactly like they were in residency. I made my way here due to the ability to join people that I trained with which is unique. So, I was able to join that OBGYN group which consisted of everybody from the University of Florida where I trained that at the time. And I have to admit at the time I was kind of lost because I felt like the idealistic approach to care, which really should be everything we’ve been talking about just got muddled with all the noise that’s unfortunately, that was a long time 25 years ago, the noise is still here you know it’s still here. So, I stumbled upon this fellow that they said you should meet. So, we met at a restaurant called Toast, which now is in 37 states, I think. But at that time was the first one. It’s a creaky little place. I was probably bigger than the place itself, you know. But we walk in there and I see this, you know, blue-eyed, blonde-haired fella and he’s talking a language that I really enjoyed listening to. I said man that is exactly what we are looking for to be able to do. And using words back then that again now are commonplace, it’s everything that we talk about. So, we decided to set on a journey together. That was in 2003, 2004. And what we were able to do was to grow both our practices based on what I call a chassis of non-negotiables which were all centered on what’s the best for the patient and the communities that we serve until we felt like we couldn’t commit to that in the environment we were in because of outside forces. Not to blame anybody, just the way healthcare is. And so, we took a leap of faith and then, you know, here we are with OneHealth. I’ll steal Doctor Cook’s comment that you know healthcare is not a 0-sum game. if it is, all you do is create tribalistic approaches, you create transactional approaches, and those things. So, it was very important for us not to discount all the most important elements of the healthcare journey in the health system is a big one. So, we’re proud of what would be able to do with OneHealth. This partnership that we’ve done. Not only partnership with Advocate but also partnership with our CHESS partners to really move the needle. And listen, when you’re disruptive, it is an upward, it’s you, you’re going you got headwinds and you’re going upstream that would be the definition of disruption. But I tell my team all the time, I think they’re tired of hearing it, but I’d say it all the time is that the tension is the work. And the tension is the work. At the end of that tension, we’re going to make differences. And we have. And so, that that’s what really what OneHealth was built on.

Your mission statement is that you are a value based primary care platform that enhances the patient experience, improves the health of individuals and populations, and reduces medical cost with a laser focus on provider wellness and care for all. So, talk to us a little bit about provider wellness. So, your introduction your introductory comments were actually very insightful, and I think provide some insight into this, but talk to us about provider wellness, why that’s so important, and what steps are you taking to try to ensure that your providers find joy in the practice of medicine, which seems to be lacking today.

Dr. Sharawy: I’ll start with that. And, you know, there’s three physicians here talking to each other right now. And so, we’ve been through, I’m not going to say we’re old, but we’re you know we’re OGs, yeah so all of us would probably not be in any way surprised to describe our careers that there was burnout involved in that. So, physician burnout is very real. We’ve experienced it. We spent the last I would say six to seven years seeing a lot of people talk about this subject. There’s a lot of data. OK so it’s not something that just say, no there’s a lot of data to support it. And we actually know the big reasons why based on that data. So, what I would say is the good news is we’re in an acknowledgment phase in healthcare. OK, but I think the bad news is there a lot of people talking about it but there’s not a whole lot of solutions to that. There are all kinds of people that make careers building on this concept of provider burnouts. Um, and we have to take it a step further. So, we’ve got to actually change the environment. So, when we talked about OneHealth and we talked about, and I think the mission statement says it, there’s a lot of things in that mission statement. None more important than the other. All important but none more important than the other. So, in order to be laser focused and take care of a for all mission, you got to have providers that are happy. That want to wake up and come to work happy. So we spend a lot of intentional time on trying to understand how do we take, and I’m going to use OBGYN again because I’m an OBGYN, how do you take a staggering statistic where any given time, and more in female than male I’ll say, and maybe because the males don’t admit it OK that that could be part of it, but that at any snapshot 68% of OBGYN will describe themselves as burned out. In any industry that’s an epidemic. OK yeah but in healthcare we take it on the burden as providers and physicians. Now the good news is we do the best we can and still take good care of people but then everything else suffers. So, we’ve very focused on how do we create environments, which means giving people the autonomy and the latitude to massage their schedules in a way that allows them to have work life balance. Because one of those things that is the number one reason for burnout is an overbearing administrative burden on providers. So, bringing them back into the equation of decision making to deliver. So OneHealth is, and you know we could spend a lot of time in in talk about examples of what we’ve done, are we there yet? No. Are we ever going to get exactly there? Maybe not. But I’m a big believer that the journey itself is 90% of a solution to doing that.

You’ve got your providers engaged and they know you’re listening, which is critical. Dr. Cook?

Dr. Cook: We’ve always said we’ve seen, you know over the years, so many physicians say they would never tell their kids to go into medicine. That they would never do it themselves again. And to me, that was so heartbreaking. I’ve loved every single day I’ve been a physician. I feel like I’m honored and blessed and what a gift it is. And I started thinking about why would I feel this way. And why I would tell, none of my kids went into medicine, but I would tell them all to do, and others not feel this way. And I know that Doctor Sharawy and his group feels that way and most of the physicians I’m with it at OneHealth feel that way. And it’s not that they’re, you know, I see these things about resilience. Doctors need to be more resilient. There’s nobody more resilient than a physician. They have to go through undergrad in a cutthroat way. They’ve got to join get into medical school and fight their way through that. They get into residency; there’s nothing more tough than residency. And we say they need more resilient. What they need is what Doctor Sharawy was speaking of. They need autonomy. They need to be the quarterback if not the owner of the team. Not the water boy or the running back for others. And they, we don’t need to put them through a several day training of resilience then put him right back into hostile fire and say you need to accept that. We need to help physicians regain that joy of medicine through autonomy, ability to change and affect the environment they’re in, and most importantly be that advocate for the patient that they want to be. And we’ve not been able to do that medicine or replicate that many times because of so many factors. some self-imposed, some imposed by the outside world. We’ve allowed a doc to become more of a widget in a system that works nine to five and gets burned out very quickly than a professional advocate for the individual. So, I believe we’ve got to a really good medium in this journey getting to a place where we can provide that for our docs.

That’s great. I think you’re spot on. Let’s talk a little bit about the for all part of your mission statement and patients in particular. Thinking about the doctor patient relationship. I think that’s something that in our world of taking laptops in the room and looking at an EMR and I just think patients feel disconnected from their physician and their provider because of all of the tech that is introduced into the exam room, which leads to burnout for physicians, I think. But it’s also frustrating for patients.

Dr. Cook: And I’ll say this, this is why that Sharawy, myself, and our partners were hit right from the beginning. We’re for all. OK. And for all doesn’t mean band-aid care, patchwork care, or even delineation of who a human being is based on how they pay for healthcare. We’re all the same. We believe anyone in our community needs equal access to concierge medicine. OK phenomenal medicine. So, we we’ve spent our whole career making sure that that’s part of the ilk of everybody we’re with. You cannot judge an individual by based on how they pay. You can’t deny care based on how they pay. You have to be accessible to everyone equally. So, I want to make sure that, that that is a cornerstone in the foundation of who we are. It’s one of our eight pillars that we will never not satisfy. Umm you know. But then the other part of that question is how do you treat individuals like individuals in a world of high tech and digital and everything else. Well, I often get residents, I teach residents, and there’s this one thing I’d always ask them, the most important thing that that you need to tell me about Mr. Smith you can tell me pretty quickly. Go in there and do what you need to do and come back and tell me that most important thing. And the residents or medical students would go in there and they would spend 30 minutes, they would spend most of the time in the computer. And always tell you know individuals no one’s in the computer, they’re sitting in front of you. Right, and they’d come back and they’d give me a litany of things that they got out of Epic, or Cerner, or Allscripts, none of which were what I was looking for. I’d say go back in and spend 15 minutes. You can get it in 15 minutes. They go back in, come back out, still they wouldn’t have it. I’d say you can go in in 30 seconds and get what I need. They said in 30 seconds? So, they would go in, most of them would come out. And I’d say 1 in 100 could give me sort of close to the answer. Now what I’m asking for is what is the color of the patient’s eyes. It was rare that anybody ever looked into the eyes of the patients long enough or intently enough to give me that. Now I would tell them, if you don’t do that, you can do an algorithm of care, you can treat their blood pressure, you can treat certain things, but to really get to their soul and cure them and become an advocate for them for life, you got to be able to stop the world and look in their eyes and connect with them. One of the fears that I have in healthcare is we’re about a generation away from that going away. Not only is it the for all mission long gone because everybody’s taking their sliver of health care and taking care of it and sending it away, and we actually marginalized individuals or exclude them from care and somehow think that that’s right. But we are training a group of physicians to be 9 to 5 providers. And often, not always, often, most of the time docs come out they really are energized. But then whether it’s the EHR, whether it’s the litany of lists they got to perform, whether it’s the time frame they have to see the patient, um or whatever is bounding them to something that that doesn’t make what I call real sense, they’re disconnected from their patient. I’ve been to the doctor, and I’ve looked at my doctor after being there I said hey do you never looked at me. You just looked at the computer the whole time. I’m over here. So, what we really want to be able to do for our physicians, and this is some of the things you know we’ve talked to you about, and CHESS, and others is there’s a lot of digital products that are built to put on top of the broken system which actually make it a somewhat more difficult for the provider to take care of everyone and take care for everyone well. What we want to do, and you’ll hear more of us say more about modern primary care, is build this model that robustly connects the individual with the provider and makes it so that it’s a sacred relationship that can be really made better. And that can’t be done with a lot of the things we’re doing now. Definitely it can’t be done if you’re making the primary care physician, the OBGYN, the widget in the game because they sort of begin to fill a role that they can’t get out of.

Dr. Sharawy: Tough act to follow. You know, too bad he’s not passionate about that subject. I think it’s you know the human connection is the key to everything. And the danger that we have is to overshoot all the technology and diminish that. And the other thing is episodic care is one of the biggest problems in what I would call an unsustainable model that we’re in. So, you also run the risk of creating an environment like David’s talking about where you diminish the ability to take care of the holistic human being, which is so much more than the snapshot in the room, um, and you start doing more episodic type care, which only leads to fragmentation, to lack of identification of things that could be prevented. I tell people all the time, we’re doing this to you at 40 so you don’t so you can walk at 80. You know, do things that you want to do at 80. So, those are things that I think concern all of us here in this conversation and we need to be part of the decision making on how to right size that and make it right. I think that’s critical that’s what I would add.

Well let me just take this opportunity to say thank you Dr. Sharawy, Dr. Cook. It’s been great talking to you this afternoon, hearing more about your passion for provider wellness and how you’re trying to address that. I think your for all mission is, I hate to use the word commendable it sounds understated, but again I’m inspired by the work you guys are doing and um happy to be a part of it as CHESS Health Solutions. So, look forward to connecting with you next time.