Opportunities for AI in Healthcare - Spencer Dorn (UNC)

0:00 But I think we need to break free of our current note writing process, right? We've all for not only have not only has the interface and basic technology not changed for decades, as you mentioned, but the process, the note writing process, the process of, you know, subjective, objective assessment plan, that's been around for many decades. I think it was Dr. I think his name was Dr. Weed created that in the 70s and 90s. And I think that's a, I think it served its purpose, but you know, rather than using AI to write the same notes we write now just faster and with less ease, maybe it's time to rethink how we capture information and do we need to write notes or can we just capture discrete packets and then later reassemble them kind of instantly based on what we need at that point in time.

0:57 So I think over time, I think we'll move in that direction of like new paradigms for capturing information, new paradigms for displaying that information, probably moving beyond the mouse, the keyboard, the screen to more multimodal types of approaches. Voice would be a big one. And but yeah, who knows, who knows where we're going with all this. It's exciting to consider. Thanks so much for joining me Spencer. I'm excited to have you here. Thanks for having me Richard. To get started, tell me a bit about your undergrad career.

1:38 You chose political sciences and then you decided to pivot to medicine, take me back in that time and help me understand that decision a bit more. Well, strangely, when I was six or seven years old, my father sat my twin brother and I down and said you could be a doctor or a lawyer when you get older. And my twin brother became a lawyer, I became a doctor. So I think it was in some ways, destined from the start. When I entered college, I was only 17 years old. And I thought I want to go into medicine, but I didn't really know and I thought maybe I should study other things as well. So I was interested in political science, government, and decided to do that in case either medicine didn't work out or maybe to make me a little more well rounded.

2:29 But yeah, really, I was kind of pre-med from the get go. I just wasn't 100% sure and I want to learn other things. Okay. Let's move forward to you, Perseeing your Masters in Public Health and Masters in Health Administration. Why did you decide to do those degrees and how have they helped you? I just, I like to learn. I guess I've been in school. I'm still attached to a university, of course. So I guess I've been around academic institutions my whole life. And the first degree, the MPH, was part of a fellowship I did in digestive disease epidemiology and it came with the opportunity to pursue an MPH at the Carolina School of Public Health, which is world class.

3:20 And it was all paid for, so I figured why not. I was interested in developing skills, research skills, and understanding methodology. The second degree came years later when I was working in healthcare already and I was developing interest in healthcare leadership, operations, administration, and my boss at the time again kindly offered to pay for me to get a degree at the same school of public health. Didn't have to travel, was able to do it on nights and weekends. So jumped at that opportunity as well. I can't say that those degrees necessarily shape what I do on a day to day basis. You know, just like medical school, you go to medical school, they teach you a lot, but who knows what we actually use when we practice.

4:06 But I think it's a way of, or I think at least for me it exposed me to different ways of thinking, different people, relationships, communities. So I'm sure it's kind of influenced some of what I do, although I haven't thought of how it does on a day to day basis. What are the degrees? There were fun degrees to get, so I enjoyed doing it. What are you excited about when it comes to AI and healthcare? I know there's a lot of talk about AI. Replacing physicians, augmenting physicians, or up-leveling advanced care providers to provide the same level of care as physicians.

4:46 Yeah, this question, this answer is kind of a cop out, but I've been thinking a lot about AI for the past several years, especially now that everyone's excited about it, having discussions like this. And I've come to settle on the greatest short-term opportunity of AI is not necessarily intrinsic to the technology. It's that it gives us a chance or a imperative to look at who we are as physicians, as clinicians, and what we do and how we could do it better, whether or not doing it better actually involves AI or any other technology. So really what excites me most about AI today is the chance to reflect, the chance to consider how healthcare should be where physicians and other clinicians and healthcare workers fit into the equation and how we can map out a better way forward.

5:48 Of course, I believe that AI is part of the solution in some instances, but I think even more fundamentally, it's a chance for us to really do some deep contemplation. The FDA for quite some time has been okay with AI being a black box when it comes to radiology specifically, but now it's moving more towards clinical decision-making in terms of clinical decision-making support tools. Just curious to hear your thoughts on having a black box in that instance, and then where do you think liability should lie? And our state medical boards and our colleges in Canada have been very clear that liability lies with the physician using the AI.

6:34 And I know you talked about this recently on LinkedIn as well, so I'd love to get your thoughts on that. Explainability is a key area to consider. We of course have to preface this by saying we don't understand how we come to many of the decisions we make when we're working completely independently. We don't know how many of the medications we prescribe work. We don't know how some of them we arrive at some of our diagnoses. So on the one hand, you can argue that the human mind is a bit of a black box as well. What's different with AI, of course, is computers are hard to hold accountable.

7:17 If you made a diagnosis that was completely wrong and negligent, your board or your hospital or even the patient could have some recourse. And even aside from that, I think malpractice concerns are way overblown. I think we intrinsically feel we want to do what's right for people as physicians, and we feel that responsibility, that oath we take, do no harm first. So while we cannot explain many of the decisions we personally make and we can be a bit of a black box on the flip side, at least there's a level of accountability and hopefully alignment with the best interests of those we're taken care of.

8:03 So when we move to AI, some of it, of course, is explainable. We conflate AI as being everything, right? But there is a lot of AI that is explainable that's very rules-based, but I think what you're alluding to are more of the machine learning models, and especially the generative AI, where detecting some patterns, creating some patterns, we don't know how it got there. And I think that is a key challenge for practicing medicine. Can we just accept the black box or not? What degree of confidence do we have in the output? And I do think there needs to be regulation because individual clinicians lack the expertise to evaluate or the sample size, right?

8:50 Maybe if you're personally using it in your practice, working in a nursing home, maybe spit out three correct differential diagnoses in a row, but that's only three, right? You're bound to butt up against some limits. So I think explainability is a key challenge. I'm not sure what the answer is. I'm not a regulatory expert, but I think there needs to be some degree of regulation to ensure that the tools that we're using, we can trust, especially because we can't necessarily figure out how they arrive at their answers. Our human nature pulls us towards wanting a deterministic model of healthcare, specifically when we're faced with diagnoses which have a bigger impact on our health, like cancer, we want more surety.

9:41 Medicine just doesn't work like that. It works on probabilities and AI, especially charity of AI, is in line with the probabilistic models of medicine. The big gap here is patients don't know this, and we don't share this data with patients because we think it will increase patient anxiety and in practice anecdotally it does. Do you think a better model of medicine is with the probabilities and the confidence intervals to an extent, or maybe just the probabilities because it's easier for patients to understand, are shared openly? For example, if you come in with a strep swab and we do a swab, if it's positive, there's 95% chance you have strep one in 20. You don't. If we don't treat it, there's a one in 10,000 chance we'll progress to an abscess, one in a million, you'll die if we treat it.

10:25 Three in a million chance you'll get rheumatic heart disease. Do you think this complete transparent way of medicine is just too much, or do you think this is where AI can really come in and spit out these probabilities? And really we can move towards patient-centered medicine where the eventual goal would be, you know, in 500 years the patient is their own doctor. It's hard to think about 500 years from now. I think that medicine is much less certain than people think it is. And we think, or at least the general public often thinks there's one right answer for each problem.

11:10 And the strep throat example is a good one because strep throat actually, we kind of have pretty good information, right? Swab the patient. Is it positive or is it negative? If it's positive maybe you have to worry about colonization and young children, but for the most part you can say, okay, this is strep throat. You have these symptoms, you have a positive test, and then there's loads of evidence in terms of the best treatments for patients. And as you mentioned, the purpose of treatment, both to resolve symptoms and to prevent complications. But most things in medicine are not as straightforward as strep throat. You think of things, you know, you mentioned cancer, cancer is not one thing.

11:54 You know, even people with the same type of cancer, the same stage of cancer, there may be different diseases, different biology, certainly different preferences, different goals of care. So it's hard to, on the one hand, I think we must admit that medicine is much less certain than people realize. On the flip side, I think it's hard to have those conversations because it assumes that A, the patient we're working with wants to hear that. B, they have the interest, time, and capacity to make sense of the information that we present.

12:39 So I think it's interesting what you suggest that perhaps you may either interspersed and help people understand how to listen, how to take risks, and how to use that to help people take drugs. And that's something that I've long thought of as a problem in the US. So, you've also been to a financial planner. So, in the old days, you went to a financial planner, they picked stocks for you, right? Like, it wasn't really that scientific, they picked stocks, they told you how much you should save, maybe somehow diversify your portfolio. Now, if you go to many of the larger financial planners, they'll run probabilistic models.

13:24 If you, Alec, they'll figure out what your risk tolerance is, what your goals are, they'll try to quantify that using questionnaires, and then they can run models that show if you went this level of aggressiveness, these are the potential outcomes in 10, 20, 30 years. If you went with this strategy, these are the potential outcomes. So I think that's a potential way that we can use AI to better explain decision or the implications of decisions and help guide people. But as you know, some people just, I trust you, Doc, do what you think. And other people would want that. So, yeah, I do think there's an opportunity there.

14:06 And I think it'll take time to figure out how we harness these tools, of course, but I do think there's some possibility. Let's move on to technology. The way we interact with technology really hasn't changed in about 30 years. We still use a screen, we still use a mouse, we still use a keyboard. I think the future of EHR is more like in minority report because where our interaction with the patient is preserved. And we're not distracted by a mouse or a screen or a keyboard. It's something more natural. How do you think of the future of EHRs? How do you think of the UI UX in that case? And what are some, what's two things you would change about the EHR if you could?

14:53 You know, all those questions need a follow up question in which is what is the time horizon, right? I think at least in the US health systems have invested billions, individual health systems have invested hundreds of millions, but collectively many billions of dollars in adopting enterprise-wide electronic health records. And physician practices have as well. And if you've been part of that change, you realize how difficult it is and how unlikely it is that they want to go through that exercise anytime soon. Especially because there's so much of how health systems and practices run now are really centered around that technology.

15:39 So I think over the short term, we're very unlikely to see moving towards newer electronic health records. I think we're more, much more likely to see layering tools on top of the EHR that can help with some of the challenges you mentioned. For instance, I'm sure your listeners know this most probably the widest clinical use of AI in healthcare right now, at least newer AI, not kind of rules based expert systems, etc. Is AI scribing ambient intelligence for clinical documentation, right?

16:19 So liberating physicians from the keyboard from the mouse from the screen so they can just speak to patients, have a conversation and voila, the note appears in their inbox for them to edit and finalize. So that's an example, I think of how we will layer technology on top of the EHR rather than kind of scrap the existing EHRs over the short run. Another example, I think a good one would be a summarization tools, right? All this not only are we overloaded with information in healthcare and in the EHRs, but the information scattered in many different locations. So trying to figure out what went on when is often very difficult, takes a lot of time, sometimes, sometimes riddled with errors and limitations.

17:14 So again, so layering on a summarization tool and AI tool that can summarize the existing EHR data on a specific patient or on populations of patients can help kind of overcome some of those challenges. So I think over the short term, that's what we're more likely to see. We're more likely to see some incremental benefits by layering AI on top. I think the longer term question is interesting and obviously purely speculation. But I think we need to break free of our current note writing process, right? We've all for not only have, not only has the interface and basic technology not changed for decades, as you mentioned, but the note writing process, the process of, you know, subjective, objective assessment plan, that's been around for many decades.

18:07 I think it was Dr. I think his name was Dr. Weed created that in the 70s and 80s. And I think that's a, I think it served its purpose, but you know, rather than using AI to write the same notes we write now just faster and with less ease. Maybe it's time to rethink how we capture information and do we need to write notes or can we just capture discrete packets and then later reassemble them kind of instantly based on what we need at that point in time. So over time, I think we'll move in that direction of like new paradigms for capturing information, new paradigms for displaying that information, probably moving beyond the mouse, the keyboard, the screen to more multimodal types of approaches.

19:00 Voice would be a big one. And, but yeah, who knows who knows where we're going with all this. It's, it's exciting to consider. I cannot agree more with you, even in my almost 10 years of clinical practice, I've seen a shift from where notes used to be to outline our clinical thinking and for colleagues to follow us on. And they have shifted to be more of a tool of increasing billing and reducing liability where we see these notes, which are pages and pages long with just repeated information. Do you think our clinical encounters and notes need to sit somewhere that is removed from billing and liability to move forward into a recording process that actually captures our clinical decision making.

19:54 Well, well, a few reflections. One is the note writing process. Yes, it serves a purpose for capturing information so your colleagues can read what you did and for billing purposes but one, in my opinion, this is something I often talk about. The note writing process is very valuable for the physician. It's an opportunity for us to synthesize information, clarify our thoughts and explicitly state what we think is going on. And I practiced, I was in medical school in the late 90s, early 2000s residency fellowship and the early 2000s. So I practiced for a little while on paper.

20:37 And I wouldn't, we shouldn't pretend like those days were perfect because there were challenges, most of all getting information, right finding information had to walk to medical records or get faxes now everything is instantly available. But people were much physicians are much more selective with what they put in their note because they had to write it by hand. You couldn't just pull everything in with, you know, one keystroke. So the notes were harder to read but I think they're actually and harder to access, but I think they probably were higher in quality it's like that apocryphal Mark Twain quote that he would have written a shorter letter if he had more time I think people put more energy and effort into the notes.

21:18 And it was really, you know, it reflected clear thinking. So I think that's one thing we should keep in mind with notes is the note should actually serves a purpose beyond billing. Clearly communicating with your colleagues with your future self but also it's, it's part of the act of thinking. So I would love for note writing to focus more on that and to be free more of some of the extraneous uses that we use it for. In the US, the, the E&M billing guidelines actually changed a few years ago where in the old days, there was a menu of requirements in order to bill different levels of service.

22:02 Okay, so if you saw a patient in clinic, you had to, you know, state what their history their present illnesses, maybe their past medical history their family history, a 10 point review a systems document of certain level physical examination, certain level of medical decision making you added all that up and that determined what you were able to bill was at a level five console to level four, etc. Well, a few years ago, the government changed those regulations and started allowing physicians to bill based on time, based on the time they spent with the patient, including the time before and after the visit on the same day so pre charting, reviewing images, etc, etc.

22:48 So, we actually now have the opportunity to break away from that old system, but what's ironic is that you physicians have and if you look at least epic last summer published data on this, our notes are actually longer, since those new regulations went into place. And then they were before. So I think it's easy for us to complain oh insurers oh the government they want us to do all this. When in fact often the challenges we need to change our behavior. Right. So, I would love to see note writing, go back more towards its purpose of an exercise and thinking and clear communication limited, limiting the amount that we're writing but, you know, explaining what we think is going on and then in the future.

23:39 I think there's a great opportunity for software to summarize different packets of information to meet, you know, the need at that specific time. I don't know if I answered your question or went off on too long of a tangent but let me know. I'm going to share a phrase Charlie Munger show me the incentives I'll show you the behavior. If you had a magic wand, and you could change the billing you could change the regulations. What would you change so note writing moves towards the type of notes where you imagine which are, you know, we are not compromising brevity for clarity.

24:21 I think it's already happened as I mentioned I mean there still are other, you know, risk scoring there still are other aspects I won't pretend like everything is fixed but time based billing that's that lets everyone off the hook I spent 12 minutes with the patient I spent four minutes before and after the visit. And that relates into this level of service and then just write what I want to write so. So that in part, I think it's some of it clearly you know when you mentioned incentives, the incentive problem. In my mind, the main challenges in healthcare are behavioral and behavior change and why do people be change behaviors as you mentioned Charlie Munger's quote.

25:02 So, you know, there's a lot of difficulty there needs to be some sort of incentive to change behavior. And we're mostly stuck in a system where the incentives are misaligned between the different parties. It's cliche of course but we're still mostly paid based on the amount the volume of things we do more than the value of the services we provide. Of course it's hard to actually figure out value that's one thing that one key challenge to that movement. I think, I think trusting or finding other ways to assess the amount of work done besides the length of the note is a major positive.

25:43 But physicians still need to find ways to change their behavior get out of their old way of doing things in order for it to make a difference. So, the thoughts in the pay wider model of healthcare with the pair also delivers the services, like the case or permanent model. Do you think that's a better model versus where the payer and service provider are separate. I think it depends is the answer. I think the Kaiser model is is wonderful. I think that the incentives are aligned. The physicians who work there generally are pretty happy now they're self selected group.

26:27 I think the patients in general are happy not always. I think it's a nicely aligned system that frees physicians from having to do things like document extraneous information. Worry about how am I providing care I don't want to provide care over a patient portal because I'm not getting paid to do that. So I think there are many benefits to that sort of model. Now the flip side is Kaiser has had struggle expanding to other areas. They're, you know, they're largely in California, they're little pockets and Hawaii, Colorado, Colorado, Pacific Northwest, they're embarking on this new program as you probably are aware to expand to the East Coast through partnerships with guys in Go.

27:12 And I think that's been announced when yesterday Moses Cohen health here in North Carolina. So we'll see if it if it can scale and spread. But there's something unique about Kaiser and that where it developed when it developed that's allowed it to stick that hasn't been replicated at scale and other places. But I do think that's a nice model I think I personally I'm a salary physician I work for a university. I tell my patients all the time I want to do it right for you I'm not getting paid an extra dollar whether I'm whether you do this test or not. I have zero incentive to do more than someone needs I just want to do the right thing and for me personally it's so it's a.

27:57 It's a wonderful way to practice. And but I realize it's a it's a privilege to be able to practice in this type of environment so yeah I think ideally there is aligned incentives where there's alignment between those paying for the care and those providing the care. I don't know if it needs to be as integrated as a Kaiser. Or the VA is another example here in the US that's even goes farther than Kaiser. But yeah, I do think aligning incentives are critical. That's not to say that there are there are plenty of amazing practices nationwide that are followed different models so it's not to say it's the only option but I do think there's something very attractive to it, at least personally.

28:43 If a startup was working on an AI scribe or a summarization tool. What would your diligence process be for onboarding it. What would make you pick one startup versus the other. I think the, the scribe tool and that's that's a busy market right now. I think with those tools they're becoming largely commoditized. And it's mostly a competition based on cost that's not to say that there are no features of the products that could differentiate but I think there's it's such a crowded marketplace that at the fair minimum they'll need to be able to integrate with the large HR's.

29:27 They'll need to have a decent interface, you know, it must be usable. They'll need to have decent performance on, you know, assessments in terms of the fidelity of the note that's being generated. But I think ultimately it's going to come down to price largely until those scribe companies can move into other areas, you know, right now they're point solutions they're doing one thing. And there are a lot of companies that can do that one thing fairly well. So I think in that case it becomes largely a largely a cost question. In terms of summarization there are some companies in that area as well they're not as many, not as many good ones that I'm familiar with and I think I have a pretty good understanding of what's happening.

30:15 I think, again, similarly, I think it's important to be able to do more than just one thing summarization. I look at summarization is almost more of a core competency than a. I'm not sure I'm not necessarily sure it's a product it's, it's a it's a it's a capability that I think links to so many different things that we do including note writing, including billing, including risk scoring, including discharge summary. I mean, so I look at summarization almost a little bit more as a more fundamental technology. And to me the question is what are the products that emerge from that. And what's the business case around around that.

30:57 If you can do a great chart summary well. Okay, well, who's who's going to pay for that. And why, and how do you prove the value of that. So those are some of my thoughts I'm very, I'm very excited about summarization I think it's, it's necessary based on some of the things we were discussing about EHR with information overload and scatter. But I think there's a little bit more flushing out to do and to determine what are the actual products here that we're using this technology for. If EHR had a summarization tool built in and one dent, would that move the needle for you to switch EHRs.

31:38 Yeah, I mean, as I mentioned earlier, I think few large organizations are switching EHRs anytime soon. These EHRs are tremendous investment that's been put into them. And there are so many different functions outside of what a physician does that they're used for that I don't think a summarization tool is enough to get all the physicians showing up with pitchforks to their to their IT departments and their CFO and saying we must switch now. And even if they did I don't know I'm not sure that that those decision makers would listen. I do think it's a valuable, a valuable feature that we increasingly need in EHRs and I, I think many EHR companies are working to build those that those tools themselves into their EHRs and you know the flip side is other companies are working to build applications that can be layered and integrated with the EHR. So, I think we're moving towards a world where either the EHR providers give that or the EHR vendors provide that or, and or there are startups or, you know, growth stage mature companies that are providing that as a service.

32:52 The main issue I have with Valley Base Care is values measured by outcomes as we know the outcomes are determined by SC, status and race and gender. They're not determined by pharmacological or even behavioral intervention at all times. Do you think Valley Base Care should move towards the process where values measured by the process and all the outcome then Adam Granz talks about this, you know incentivize outcomes you people will cheat the system to for to get those outcomes if you incentivize someone to lose weight or a strict BMI they will starve themselves, as opposed to incentivizing them to eat healthy and exercise.

33:32 Do you think there's some way we can move towards measuring the process because it's easier to measure the outcomes. That's the lazy way to measure value. I feel I would argue it's easier to measure process than outcomes if you look at the, you know, there are at least the earlier versions of the quality movement. You know, it was all about process measures. Right. Patient has this condition. Are you vaccinating them. Are you checking these labs periodically are you doing screening them for osteoporosis simple yes note checks and I think we're still largely stuck with those types of process measures in medicine outcomes are harder to assess. They don't write it takes time to see an outcome some outcomes maybe are clearly visible within 30 days but many are, you know, months to more likely years away.

34:27 And that assumes someone staying in the same health system you have longitudinal records, they're staying with the same health insurer. So I think process measures at least in my experience here in the US tend to be relied on. And then the question is, what does that mean, right what's the, what's the, I don't say, what's the value of all these process measures. Hard to say, hard to say. I used to be a used to say I used to be a zealot equality measurement zealot. I participated in a lot of measure development rounds with my professional society and I was just really into it and then one day it dawned on me that it's really, really hard to measure quality.

35:12 You know, it's one of those. I know it when I see it. It's just, it's hard to quantify this not saying we shouldn't try but it's just, it's really hard so we wind up moving towards select conditions that we can quantify value for quality for and then we select measures usually process measures and it makes me wonder how much or how good of a job are we actually doing. So, there's some thoughts. In your own department with the physicians you lead. How do you measure their quality how much do you rely on intuition and how much do you rely on structure. Largely intuition, largely professionalism.

35:55 Peer review. Simple process measures like board certification. So it's more process measure based and intuition there are some kind of more outcome so in my field in gastroenterology we have one. In my opinion we have one excellent quality measure it's add an add anoma detection rate and add anoma is a precancerous polyp the purpose of doing a screening colonoscopy is to find these precancerous polyps to remove them before they could become anything harmful. And to risk stratify people that if they're likely to grow these things we're going to see them more often.

36:36 And so, there's a measure called an add anoma detection rate which is of all the screening colonoscopies I do. What percentage of the time am I finding one of these precancerous polyps. So, that's something we pay a lot of attention to and in my practice. Because we believe it's valid we believe it's it's something that we can affect we we can show the variation across you know our 35 plus gastroenterologists. So, but that's they're few and far between, you know they're few and far between. What are your thoughts on capsule endoscopy.

37:17 It's been around for quite some time now. But now we're seeing somewhat of a resurgence but startups getting into space as well. I'm sorry my dog's barking in the background. Capsul endoscopy is a useful tool if you use it for the right purpose. You know usually the small bowel despite its name is quite long and a small proportion of patients have GI issues that are not related to their upper GI tract or to their colon. It's possible lesion is in the small bowel so capsule endoscopy is a wonderful way of evaluating the small bowel, but it's not necessarily new and I'm not familiar with some of these innovations that you're describing.

38:10 Why do you think physicians are burnt out. Yeah, that's a great question. And there's not just one answer right I think one problem or one challenge is that people think all physicians are the same. You know we all act the same we're so you know we're so different in and not just how we practice but who we are as people what excites us and what wears us down what energizes us what's most important. So it's hard to come up with blanket statements in terms of this is the specific cause.

38:50 I think there are some common themes if you speak to enough physicians who are experiencing burnout that do appear. One would be just the amount of work, I think clinical medicine is increasingly difficult our patients are suffering from more complex illnesses they more complex lives and social isolation coexisting mood disorders. Just various challenges and we're helping people stay healthier longer and the consequence of that success is that people are presenting to us with later stage illnesses or conditions that previously may have been treated surgically are now being treated medically and so we have patients who are sicker so I think.

39:39 I would say one core reason is that the work is harder largely because people have more complex needs related to that I think we've done a poor job of adapting our systems of care and our care teams to support that additional incremental work that physicians must do. So I think that's a key factor is this kind of more demands without more support. So I think that would be my leading reason I think there are plenty of others. The administrative headaches as everyone's familiar with moral injury we talk a lot about.

40:26 I think that there's a feeling that perhaps some of our patients don't value us and what we do. And not only that some are at times openly hostile even confrontational, even violent. There's a whole slew of different things but I would probably most of all it's the it's the mismatch between the work demands and the support given to do the work. And what do you think so from what I'm hearing is there's essentially too much to know and too much work to do and then we're not valid enough on top of that.

41:08 We're supported enough right too much to do for one physician alone. Yet that physician is maybe working in an old model where it's just them or just them and a nurse who rooms a patient in there, left to do everything else. What do you think the solution is here. I don't know what the solution is. I think that we're very fortunate and privileged to do what we do and how do we return that sense of joy and meaning and purpose to the work. I think that's ultimately the challenge is there will always be head every job has headaches and frustrations.

41:56 Every job or profession has the same meaning and the same stimulation and the same collegiality that careers in medicine do so I think we. We should work to mitigate some of the some of the daily headaches. Etc. Etc. But I think more than that I think emphasizing the benefits of medicine emphasizing the joyful aspects of medicine connecting physicians with purpose.

42:41 I think that's where I would go now how do you do that. That's that's a bigger question. I think one thing and this relates to burnout as well I think one challenge, at least that I've seen over my career is that physicians feel more disconnected from each other and from the system. We don't see each other as much right where are we're working in larger practices larger systems. So we're more dispersed geographically where our heads are down in our computers or phones. So we've less time to look up and actually speak to each other either on the phone or a zoom or even better in person right in the physicians lounge.

43:22 So, I think community building is really important as a possible antidote to burnout. Right, we all want to be connected to aspects of life larger than ourselves. In some it's from the work itself. I think a lot of it is from the organizations we belong to from our colleagues. So those would be areas that I would prioritize. You could go back in time 10 years ago and give one piece of advice to your past self. What would you tell him. Oh, I'll. I think just self compassion and kindness.

44:07 The path as you know anyone who I've knows it's not as as linear and straightforward as maybe we imagine. So I think giving yourself or I would advise my younger self just to practice self compassion and kindness along the way. I'm better at that as I've gotten older. That's good to hear Spencer. Where did yourself 10 years ago imagine you now and where do you imagine yourself 10 years from now.

44:47 I don't know where I imagine myself 10 years ago. About 10 years ago I started to take on leadership opportunities. I was still pretty involved in research and really fascinated with kind of the science of medicine. I'm not so sure I plan things out I just kind of follow the interests and have had good mentorship and opportunities to do different things but I. I don't necessarily think I saw myself doing anything dramatically different. I thought I'd be a doctor and help to help help lead our practice and hopefully contribute to the broader conversation.

45:30 And likewise it's, I don't know 10 years from now. I don't know if I have a specific destination I'm aiming for. I'm pretty content with what I'm doing of course help to hope to continue to grow. Meet you know for me at this point stage in my career I really like meeting people. I like collaborating. I like learning continually. I like serving the greater good. So hopefully doing all that just in some capacity probably a little different from now but hopefully not too different. So many physicians I talked to struggle with purpose we're putting this treadmill very early on, and we are said you pass this exam and this exam and this evaluation and you get into residency and you get into med school and maybe you get into fellowship passing board exams.

46:21 Our purpose is almost defined by these hard metrics were given. This is a deep question Spencer. So what is how do you define purpose now what is your purpose in life. In my purpose in life is to be the best person I could be to positively influence others my family, friends, community those I work with and patients I serve. So that's the fundamental purpose is making positive contributions, not just on a large scale hopefully on a small scale, hopefully in on an everyday basis, making things a little bit better.

47:10 I'm also, you know, growth is a is an interest of mine personal growth, learning, learning new things. Yeah, I think. Most of all I think meaningful positive contributions and I guess second would be growth. You know, experiencing new things learning new things. I think those would be core core areas that I emphasize. Last question. What's your advice to med students right now. Yeah, my advice to med students is just to do their best and to pace themselves, because it's a long road. Right, it takes a, it takes a long time which is in some ways a challenge but also in some ways in opportunity because you don't need to have it all figured out when you're in medical school.

48:08 We train for so long that we mature as people as we're training and our ideas of who we are and what we want to do evolve. So I think surrounding yourself with good people, doing your best pacing yourself, being open minded. I think careers of medicine are wonderful. There's so many paths that physicians can take. And I think just being optimistic about the opportunities and, you know, making the most of the opportunities because most people don't have the opportunities that we're fortunate to have. Thank you Spencer. I hope we can all move towards a more compassion for ourselves. And I agree building communities to connect physicians is probably the most realistic solution to the burnout we're facing.

49:01 Yeah.