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0:00 Speaker 1: Welcome to the Healthy, Wealthy and Wise podcast with Dr William Chowk-Taw. In this episode, Dr Chowk-Taw will continue his Leadership Masterclass series by covering healthcare's quality revolution. He'll explore a number of factors that are driving this revolution, factors that include the latest developments in healthcare quality and how it has changed the landscape of healthcare delivery, the Affordable Care Act, patient-centered care, high reliability organizations, lean Six Sigma and medical malpractice. Dr Chowk-Taw will also explore data and analytics and how they are used and applied to help improve healthcare. So, whether you are a healthcare practitioner, a healthcare professional, a patient or just a consumer of good information, this podcast episode is for you. Join us now as we explore healthcare's quality revolution and discover how we can work together to help improve the quality of healthcare delivery for everyone . So let's get started. Here's Dr William Chowk-Taw.

1:09 Speaker 2: Good morning. Good morning. I'm absolutely delighted to be here and I welcome you to the Masterclass Number Five. Masterclass Number Five Today we're going to talk about leadership in terms of healthcare's quality revolution quality revolution. I believe that life is about being of service to others. I believe knowledge is power. I believe leaders can change the world. You notice, i always start off with the same beliefs and these are my beliefs. And you may say with Dr Chowk-Taw why don't you talk about what you believe? I do this for two reasons. One is to emphasize the important point that we started with the very first Masterclass about talking about the brain. That is what you believe that affects how you think, and it is how you think that affects how you act, and so it's always important for us to go back individually to our individual belief and make sure that they're in sync with where we want to be and where we think life is going for us. If they are not, then change them, but to always be aware of them. For the last five weeks, i've asked you to think like doctors as we talk about this Masterclass And, as Jesse mentioned earlier, we're going to deal with both medicine and law as we talk about healthcare. One of the things that I learned. Let me

2:43 back up. I graduated from medical school in 1973. I graduated from law school in 1998. 25 years different. And one of the things that I learned is the difference between doctors and lawyers. I did not know this before. We doctors think in terms of black and white. Either my patient has acute appendicitis or my patient does not have acute appendicitis. Either my patients had a heart attack or my patient did not have a heart attack. Doctors like to have exactness. They like to be specific, but when we are not able to be specific To lawyers, there is no black and white.

3:27 Think about this. Doctors think in terms of black and white. Lawyers there is no black and white. Lawyers think in terms of grayness. Everything is gray. It's how you use the facts to make it a little dark or a little light. So it's one of the reasons why, when a doctor is talking to a lawyer, they many times there's a conflict, because the doctor is saying but I saved his life, so why in the world is he suing me for malpractice? The lawyer is saying I don't care that you saved his life, you violated section one of XYZ, blah, blah, blah, blah, blah, blah, blah. Therefore, you're going to be liable for malpractice. So it's a different welcome. So it's a difference in the way we think. Doctors think in terms of black and white, lawyers think in terms of grayness, and I'm definitely a black and white guy in terms of how I think and what an exactness of this and that. But what I have learned, what I have learned as I've gotten older, is that the world is probably gray. Most people probably do think in terms of black and in terms of grayness, but we'll go over that a little bit more as we move along. If you remember, this is your computer. Some people call it a cell phone, some people call it a smartphone. I call it an academic hand computer because you're in the master class and you're exceptional compared to other students. You're expected to use your academic hand computer and look up stuff all the time. Anytime you have a

4:59 question about anything maybe a couple of times a day you should go to your academic hand computer and put into the browser What is the meaning of artificial intelligence? Blah, blah, blah, blah, blah, blah. I always want to make sure to remind you about that. As always , i always like to include an outline, and the purpose of the outline is to let you know what we're going to talk about. That's one purpose. Second purpose of the outline is to let you know where we're just about done. So I know you want to visit people and, god bless you, you're taking time out of your Saturday to be here with us for an hour. So we're going to talk about change, and we always talk about change to some extent. We're going to talk about the Affordable Care Act, or Obamacare, as you probably heard it, because that has been fundamental to the change in health care. We're going to talk about something called HCAPS.

5:50 This is a survey that the government started doing, probably about 20 years ago 15, 20 years ago of patients to help to evaluate doctors and hospitals, and we'll go into detail about that. We'll mention about high reliable organizations. This is where hospitals want to be High reliable organizations, those organizations that are trying to get to zero patient harm, zero patient harm. One of the codes that we take as positions in essence is to first do no harm. You may not help, but you don't want to harm anybody, so the first thing you want to do is not to harm anybody. We'll mention briefly about the Lean Six Sigma just as a process of excellence, and then we'll end with medical malpractice. So when we get to medical malpractice, you know what I'm just about done. Okay, all right , here we go Quality revolution.

6:46 One of the things you hear people talk about a lot in health care is quality, the essence of what you do to a person, or are you giving them the best type of care as compared to less? best type of care? And one of the truisms that I've learned that I want to share with you, and I heard somebody say this to me a long time ago if you can control the dictionary, you can rule the world. Think about that If you can control the dictionary, you can rule the world. See, if I control the dictionary, things mean whatever I say. They mean Black, means white, up, means down and means out, because I control the dictionary Right? So you want to be very, very careful when you hear people talk about whatever they're talking about and ask yourself who controls the dictionary? Who decides what's good? Who decides what's high quality, what's poor quality? Who makes that decision? And how did they get that ability to be able to do that? Another fundamental principle that we'll address multiple times today is health care. Is health care a privilege or is it a right? Do you have a right to quality health care, or is it a privilege that you've been blessed with being able to experience More and more? now, and I'm in the category that believes that health care is a fundamental right. I do not care where you are, i do not care what you do, i do not care what you look like, i do not care

8:18 what your politics are, i do not care whether you're a follower of Martin Luther King or you're the imperial wizard of the Ku Klux Klan. If I am your surgeon, i'm going to give you the very best care and it does not matter to me. I'm not even going to ask you about your policy. Does that make sense? Because, as a physician, my job is not to judge you, so I don't judge. I don't judge. Now, that's a little different from the way I grew up, where you do judge. I look at him and I judge this and I judge that. But as a physician, my job is not to say well, he's wearing a black watch , therefore ABC, or he's wearing a blue jacket, therefore I am a physician. My job is to give you the best care possible, and that is irrespective of what you believe in, who you are. Now, everybody does not believe that, but I think it's fair to say that most in society are moving toward the fact that health care is a right. It is not a privilege. I don't care what your citizenship is, i don't care where you were born. If you landed my hospital, on my operating room table, i'm going to give you the very best care possible, and all that other stuff does not matter to me. It is not relevant to the quality of care that I give you, and this is where we're trying to get doctors and nurses and hospitals to get to today. One of the other basic principles that the federal government figured out some years ago is it pays most of the money in this country for health care. The

9:49 federal government, washington DC, pays most of the money for health care in this country. So the government said if I pay most of the money, i think I should control that dictionary Right. If you can't do it without me paying you and you rely on me to pay you, then I can decide what's what. And so then the government said I will decide, or help to decide, what quality is. No, dr Choctaw, we're going to go by your definition because I'm paying you Right, so you can have your thoughts. That's good. I'll listen to your opinion, but at the end of the day, it is my responsibility. So I'm going to tell you what my expectations of you are. Hospital X I'm going to tell you what my expectations of you are. Okay, one of the big ways this occurred in this country admittedly, you've heard about this and you sort of know about it, but it may not have been obvious to you at the time is the Affordable Care Act. And you hear one party in this country saying they're going to repeal it and they promise they're going to repeal, they're going to get rid of it. And the other party in this country said it's the best thing that's ever happened to health care in the last 20 years. And some even call it Obamacare because it was President Obama who actually pushed it through. It's similar to the 1950s, where Medicare was first adopted. Medicare did not exist until the 1950s. What does Medicare do? Medicare helps

11:19 to ensure quality care for elderly patients in this country , because when you're elderly, you probably no longer work, and the older you get, the more and more and more medical conditions you're going to develop. Just the way it is Okay . So the government decides. Well, if you've worked hard all your life or you've lived a long time, you should not be denied health care just because you're over 65 years of age. So Medicare says we're going to help pay for your health care And that's why we have Medicare. And I might add that some people who objected to that in the 1950s no, no, no, no, no, no . That's socialized medicine. People ought to work for the health care. For instance, i've been working for the last 50 years. I'm 75 years old, i'm not going to work anymore, but still it depends on whether you believe that health care is a right or a privilege. Should it only be for certain people who have a certain amount of income we have a certain amount of blah , blah, blah, or live in a certain zip code or should it be for everybody, because it's a God-given right to human beings and it should not matter who you are, what you look like. But that's the fundamental argument. That's the fundamental argument . You hear it play out all the time, every day. Three things, very briefly, that the Affordable Care Act did or does, because it's still with us. The other part was not able to repeal it. They keep trying but they keep failing. One it

12:53 covered more people and it paid for care for more people. A single parent, three to four children, may not have a job, stays on welfare or something like that. How do you pay for? if you have a sick child, how do you pay for those expenses? The Affordable Care Act helps to pay for that. It controls costs. Does somebody believe? well, you know you pay whatever I charge. Well not really. If I don't control the dictionary Okay, because the first control is the dictionary that's in the chalkbook You can't charge $1,000 for cutting a toenail.

13:33 That just doesn't work. You can't do that. I know you may have house payments. Get a smaller house. Get a smaller house, Okay. The other thing, and probably one of the most subtle and I think one of the most profound things that Obamacare did back in 2010, is that if forced hospitals and doctors help go all electronic, force us to use the computers, put down that pen and pencil and it drove the industry crazy. I know nurses they quit at hospitals because they had to learn how to use the computer. And the nurses I want to be at the bedside Doctors who said well, i'm a doctor, i operate on people, i don't want to do all that paperwork. And the government said you know what. I control the dictionary. I'm paying your salary. Quality is what I say. It is What I say it is And right, honestly, my personal opinion the government was correct Because if you're doing the right thing, why is it a big deal for you? Okay, what are the other fundamental things about this cold change? and the idea about quality healthcare is let me do it with a hypothetical, and I'm sure I've said this before. When I graduated from medical school in the early 70s as a physician, we were told that we're in charge. We doctors, i mean, are in charge. People just do what we say in a hospital. And I think I've mentioned, you know,

15:06 about how nurses used to stand when the doctor used to walk on to the ward and all that sort of stuff. But basically the response to the thing was yes, doctor. I say do X, yes, doctor, do Y, yes, doctor, no question, no, blah, blah, blah, none of that. And the government said you know what, if you go and stay a couple nights at the Ritz-Caulter, before you even get home, they will send you something and say how was our service? Did you like it? Were you okay? Were there any problems? Would you come back again? Would you recommend us to your friends? Blah, blah, blah. What's my point? My point is that quality organizations are always interested in the opinion of the customer. Who is the customer in health care?

15:52 Doctor's not the customer, nurse is not the customer, patient is the customer. And so one of the things that might last seven or eight years in full-time employment run around the country trying to help, along with the joint commission, educate physicians at hospitals about quality care, a fundamental thing, i would say it is no longer doctor about you . Used to be about you. Seven is an eight. This is now 2023. It's about the patient. It's what the patient thinks, it's what the patient believes, it's what the patient feels And so, in effect, this is what the government who controls the dictionary, who pays the money has adopted and said it's patient-centered care. So what do you do with something that's patient-centered or customer-centered? The patient is your customer. You ask their opinion. So the government, many years, came up with something called HCAPS and that stands for Hospital Consumer Assessment of Healthcare Provider and Systems . What that means is hospital consumer assessment, patient of healthcare providers, doctors and nurses, and hospitals and systems, healthcare delivery systems. So two weeks after the Medicare patient is discharged from hospital, a hospital will send a correspondence, a letter with a survey, and it will have 27 questions, only 27 questions, and the questions are in

17:25 different areas, and I'll just deal with the question about doctor And the only three questions. They ask the patient about doctor and the concern here is zero patient harm And the answers to the questions are either always, usually, sometimes or never. Okay, all the patients do is fill in the circle that says always, usually , sometimes or never. The three questions that they ask about doctors is how often does your doctor treat you with courtesy and respect? Real basic question How often did your doctor, when you were in the hospital hospital ABC for two weeks how often did your doctor treat you with courtesy and respect? Always, usually, sometimes or never? And here's the deal If the patient's answer is not always or usually, medicare ignores the other two scores.

18:24 They don't care about never and sometimes It is zero. You get a zero for that. The only thing they score are four for always, three for usually, that's all Okay. Second question they ask the patient about the doctor. How often does your doctor listen to you? Real basic stuff. Doctor comes in making rounds. Good morning, mr Smith. How are you this morning? Mr Smith says oh, you know, doctor, i had this horrible headache and my eyes have sort of been watering and my neck is sore. He says okay, you have a nice day, mr Smith. God bless Anybody in the next section. How often does your doctor listen to you? Real basic stuff, right? Third and final question They ask the patient, medicare patient in this survey they send out. How often does your doctor explain in ways that you can understand? How often does your doctor explain in ways that you can understand? One of my responsibilities that I won't mention the name, but a small hospital in West convenient California is that I would try to educate the doctors about sitting when you make rounds. You know, doctor comes in morning, mr Jones, blah, blah , blah, blah, blah, blah, blah, blah, blah, blah. Have a great day. Any questions? And you know , leave in the room. And usually when the doctor says are there any questions, his hand is on the doorknob right Because he's going out the door. And do you

19:58 know and this is what I would explain to the doctor, because I learned this, most patients believe very strongly that doctors are extremely busy. Number one, number two most patients are extremely, extremely, extremely respectful of physicians. They will not ask you a question if they think you're too busy to answer. They will not. And they can have a question. Oh my God, i've been waiting all night and I, you know, i want to make sure that I grab Dr Chalker this morning. And so what? I tell the doctor, you've got to give them permission to ask you a question . And how do you do that? You say thank you, mr Jones, do you have any questions? And you follow it up with one simple sentence I have the time. So take your hand off the doorknob And say do you have any questions? Mr Smith, i have the time. When you say I have the time now, you're saying okay, he's given me permission to ask him a question. They will not ordinarily, they will 98 percent , 99 percent of the patients said I do have this pain, that I want to answer Dr Bob, but Dr Choctaw is so busy. He's so busy . I see him running up and down the place and this and that I'll be okay. I'll be okay, but it is our responsibility to go to

21:29 the patient. Patient should have tried to figure out what to ask us. Our responsibility is do you have any questions? That's the huge change in health care where it's basically top down and you do what we say and you do the way I say it. I remember when I would go on rounds and I'm wearing my little white pants as an intern and then there's the middle resident and the senior resident, then there's the professor in surgery at Yale. The professor would walk into the patient is going to have surgery and he would look at her and he would say something like this tomorrow morning I'm going to take you to surgery at 730 in the morning and I'm going to do a colisostectomy. The operation will last approximately two hours and four to five minutes. You will have some discomfort, i will give you pain medication, you will be in the hospital maybe about two weeks and then he walk out of the room. I had to answer the same What. What did he say? And what would happen was the resident would stop and say Mrs Smith, do you have any questions? Professor Choctaw is so busy, but I'll ask you a question And that's how we used to do it. So hopefully, most of that chain where we stopped and we even tell the doc sit in a chair by the bed. So if you feel comfortable, sit on the bedside. Some do that and say do you have any questions?

22:48 Why? Because most communication is non-verbal, it is not what I say, it is what I do. So if I don't say I have the time, but if I sit on your bed or if I pull up a chair beside your bed, i'm telling you yeah, i got some minutes. Talk to me Very important. And so this is what's happening in healthcare. Then Some hate this. Some vicious hate this. Some in healthcare hate this, but I think it's fair to say that the majority of us are moving in this direction And this is one of my jobs, which I loved, among other things, one of the things that I have learned, like a lot of times, doctors say well, you know, i practice in San Gabriel Valley and it is so diverse, you've got so many different ethnic groups and so many different, so many of that. I can't be responsible for making sure that everybody understands everything. It understands me and whatever, and what I would do, what I would give, like my little quick-to-minute lecture to the doc I said respect transcends all culture. You don't have to be an expert in Mandarin or Chinese or Tagalog or Filipino or on and on and on. Just be respectful, be respectful. And how do you be respectful? Most communication is non-verbal. Read the room. You walk into a room and father is the patient, mother is sitting beside him and

24:19 the kids the adult kids are standing in the room. What do you do? One of the things you wanna do is you speak to father, but you wanna speak to mother. I used to shake hands with the little kids. They'd all grin and laugh cause they thought I was silly. But what's my purpose? My purpose is I am respecting you, i see you. I see you, you're not just a chair up against the wall. We'll come back to that. Let me say a real quick word about Ling Six Sigma and I won't spend a lot of time on this. But those of you who are very process-oriented and much of this has come from institutions like airlines, industry and others that have to get everything right And if they don't get everything right, if they make mistakes, so things don't go right, they all die many times along with the patient. Big incentive, big incentive, right, different from healthcare. Different from healthcare where you say, well, he was 900 years old and blah, blah, blah, blah, blah, blah.

25:19 But if you're on that same plane , right, you're on that same plane, you don't need a bigger incentive. One of the most important I think one of the most excellent systems is Ling Six Sigma. Ling, real quickly, just means eliminating waste. Eliminating waste which you guessed is one of the biggest waste when you go to the hospital or go to see the doctor , what's one of the biggest waste, something that should not happen. You think, what are those rooms that you fit in? waiting room waiting. Why do you have to wait? What dictionary is that in? Who says that you gotta wait two hours before your doctor sees you when you go to her office? Where is that written that you have to wait two hours? But one of the things that I used to do in my office, in my office manager is sitting right in front of me. She ran not only me but my office. We had a policy. Who started? We had a policy in my office If you had a one o'clock appointment to see me but you arrived at 1230, we would see you at 1230. Because we were already there 30 or an hour before your appointment time. Right, Because we scheduled appointments. We know what time you're supposed to come in And we would see you because, the idea being number one, to show respect, my time is valuable. Who is your turn? But why should you have to wait for me? Why should I have to wait

26:52 for you? Mutual respect okay, so lean eliminates waste. What Six Sigma does is Six Sigma the one that eliminates variation. If there are six of us, seven of us in this room, and we all wanna get out that door, but we all wanna get out of this room, but we come up with seven different ways to do it. Some go out the door, some go out this door, some go out the window, some go out this other way. That's really pretty inefficient, wouldn't you say? Now, multiply that in a huge hospital delivery system, a thousand beds with a thousand plus patients. So to have efficiency, to not make mistakes, you need to have a simple but effective process, and that's what Six Sigma does, right. Six Sigma says I would be on rounds in a hospital, c and Chicago, and they would be presenting to me about something they're very proud of and they say you know, we decreased our infection rate from 80%, we improved our efficiency up to 80%, 85%, and nobody in the area has hit 80%. And I was saying you're good. I said but why not 90? I said, well, nobody does 90 . I said I'm not talking about all those other people, you're the superstar. I said well, why not 95? Why not 100? When did we

28:25 decide that 80% was excellent? Who wrote that dictionary? And then I would tell them true story. I said because if I'm a patient in your hospital, or my wife or my children or my grandchildren, i want 100%. I'm not impressed with the 85%. Good job, good job, but I expect you to do more. I expect you. Six Sigma to break it down mathematically says 99.999666, that that distance between 99% and 100, you can do better. That makes sense. Six Sigma says you need to be not at 85%, it needs to be at 99, but even at 99, you can do better before you get to 100. It asks us you never stop improving. There's always something better that you can do . And that's actually been articulated. And I would encourage you to take that handheld computer that you have in Lookup Lean Six Sigma Real quickly. This is just the roadmap for it define, measure, analyze, improve, control. I'll just say a quick word about define, whenever there's a problem, a system. Let's say Dr McClure is the owner of a small hospital, 250 beds. In his hospital he has OBGYN department for delivering babies. He has an emergency department where patients come in if they have emergencies. One of his managers comes to him and he says Dr

29:56 McClure, we have a problem. And he said but what's your problem? And she says well, we have a lot of people who come to our emergency room but they leave before they see the doctor. They leave before they see the doctor. We call it left without being seen. Okay, leave before they see the doctor. But he says why are they leaving before they see the doctor? She says I don't know. She said what is the problem? She said because we have all these people tired of and, more importantly, we aren't doing anything for the community. So what are some of the reasons they can be leaving without seeing the doctor? Well, maybe they have to wait too long See the doctor. If they have to wait six hours, 10 hours , would you leave your mother?

30:37 You bring your kid in because he had an ear infection. You got to go to work the next morning. You bring the kid in at two o'clock at night and you wait eight hours in an emergency room before taking him, before having him seen. So is it waiting too long? Is it they feel uncomfortable in your emergency room? Maybe it's not clean, maybe there's a lot of activity and they don't feel safe in their emergency room. Maybe they've seen your doctors walk around in the emergency room and they wear flip flops in shorts And you said whoa, whoa, am I in the right place? So what's my point? My point is, for those of you who are math enthusiasts, there's a formula for lane sixing. It says y equals a function of x. Y is your problem, y is what you're trying to solve. Y is what you've got to fix. X are the number of reasons that are causing your problems, but you don't know which one it is.

31:41 Let's say you have five x's. One you have to wait too long. Two your emergency room is dirty. Three they don't like to wear your doctor's. Look on, and on, and on and on and on. Lane sixing may help you identify which x you need to fix basically. And one final thing about defined. Whenever there's a problem in any organization or something has happened and see, we got to fix that, first thing that happens when you have a meeting. Everybody comes up with a solution Well, i think we should do this and this. And somebody says, well, i think you should do EFG. Somebody said, well, i think you should A and B . Albert Einstein once said and I always remember this when I have a problem and I've said this before when I have a problem, i spend and I have an hour fixing it. I spend 55 minutes defining the problem and five minutes solving the problem. What's my point? Most of the things that will help you solve a problem is sitting down and talking about defining.

32:38 What do you mean when you say enough without B and C? What do you mean? Blah, blah, blah. You would be amazed at how much miscommunication occurs because we say things but everybody has a different meaning. But we never asked. I think that's what the roadmap looks like with Lean Six Sigma. Again, use your hand computer to look up Lean Six Sigma. Okay, medical malpractice. So I'm just about done, right, right, right, you've been following me, right? I'm just about done. So what is medical malpractice Now I have been asking you for the last five weeks, five months, to think like doctors. I'm not going to ask you to think like lawyers. What about being a doctor? You're now an attorney. You're now attorneys. We're dealing with the Andrew Collins, hammons, jesse Hammons law practice. They are famous around the area, particularly medical malpractice, So they're the top of the line. And one of the things I learned is that people tend to like doctors in general.

33:54 People don't tend to like lawyers in general. I'm just generalizing them, but somebody once said people tend to hate lawyers until you need one, Until you need one. When you need one, you need a good one. And one of the things that I learned when I went to law school was how little I knew about the law, and the reason for that is the law is deceptively complex. You read a line that says you for God, go to prison. And you say well, i understand that. I know what a God is. I know what a prison is. I know what you for God, god, go to prison. I know what that means. But that's not necessarily true. That's not necessarily true, and I can tell you when I went to law school, I was older than the other students. They were 20 something , i was 40 something, whatever, 40 or 50 something. And one of my favorite classes was TORT, p-o-r-t, and TORT means injury And that's connected to our subject. And I was sitting. You got to say I'm one of those students who gets a class an hour, 30 minutes ahead of time.

35:06 I sit in the front row. I mean, you know the type, i got my pencils in my bag. You say them, come on, i'm that type of student, all right, so you get the picture. So I'm sitting in the front row, you know, ready, ready. And instructor gets up and says man walks up to another man, takes a gun, puts it to his head, pulls the trigger, puts him in the head, man drops and he's dead. Is that murder? And I jump up and I'm throwing my hand up. I'm on the front row throwing my hand up and he's still there. And he said, dr Chalkton, i said yes, it's murder. And the instructor looked at me and he says it depends. And I said well, even it depends. You just told me that the guy walked up, put the gun to his head, pulled the trigger. The guy was there. He said was it his house? I don't know. He said what was the man doing when the guy shot him? I said I don't know. He said was the man coming at him? Did he have a gun? also, i said I don't know what the instructor was telling me is it does depend. You've got to know the fact before you come to a conclusion. Braininess, it is not black and white. I'm a doctor, not only I'm a surgeon. We really are black and white. Give me a knife , i'll find out what the problem is. Right, no Longest, don't get nice. And so whenever you ask an attorney and I encourage you to take me up on this, any

36:40 attorney ask him or her a question And I guarantee you the first thing she will say to you . But he will say to you it depends. First thing they will say they'll say two words, it depends, because what they're saying is you got to give me more information, you got to give me more. You can't just tell me somebody got shot and expect me to come to a conclusion and not give me anything to work with. So that's the fundamental difference between medicine and law. Right, i would tell members of my hospital when I was people's bad and they would bring to me a situation, let's say harassment of some type And they would say, oh, it's terrible, this this, this, this this, this, this, this, this. We need to do A, b and C And I would say have you talked to the other party? Do you have the other side of it? One of the things I learned in law school if I did not move before, there are always two sides, always, always, always. I don't care if the guy put the handgun to the guy's head and shot, just like I was saying.

37:44 What were the circumstances around that? But what was the guy holding the guy's family hostage? I don't know, i don't know. So my point is and I really believe this is where the law helped me personally, i have, for the most part, always met a black and white type of guy. You know, blah blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah, blah. What I have learned? what I have learned is to take a step back, ask a few more questions, don't be so quick to judge, don't be so quick to think I have the answer, because many times are wrong and I don't want to be wrong. That makes sense. So. So my point is that, regards to what you think about lawyers , one of the things that the law does is that it makes you slow down and get all the facts, because you don't want to be wrong. Whatever conclusion you come to, you want it to be the right conclusion. You're right, so. So just keep that in mind.

38:41 Okay, let's go. So. Chart is a type of law that means injury, porp. Now there are two main big sections of the law. There's criminal and there's there's civil right. Criminal and civil Malpractice is civil law. It is not criminal. Let me explain the difference. If I am found in violation of a civil statute, basically I pay money, i have injured somebody or I have created an injury And to make that person whole, i have to compensate them for their injury . Okay, if, on the other hand, i am found guilty of a criminal statute, i go to jail. Think about that. Civil, you pay money , criminal, you go to jail.

39:31 Civil. Somebody will sue me or some entity will sue me and blah , blah, blah, blah. You defame me, you violated this or whatever, whatever, whatever. But if it's criminal, the District Attorney of the State of California will say, representing the citizens of the State of California, because my crime is considered a violation of the state, i violated all the members of the State of California, and that's my other point Medical malpractice is a state law. It is not a federal law. That's why it may vary from state to state. Texas may be a little different from California , but the basic parts of it, though, is the same. What is the definition? going back to what was said before about defining What is the definition of medical malpractice, the definition is acting unreasonably under the circumstances. Acting unreasonably under the circumstances. There are three elements to that definition. Three elements, only three.

40:43 Number one acting you got to do something. You got to do something. Number two unreasonably what you did was not reasonable. And third element under the circumstances. Let me give you an idea. The patient comes into the emergency room as part of a 50 car call up on the freeway. The patient comes in and the emergency room is just a big scramble. They call it down with trauma surgeons and we come down and we're taking different patients and blah, blah, blah, blah, blah , and, let's say, one of the surgeons, at the end of the operation the scar of the surgery is longer than it normally would be. That's just for the sake of argument. And the patient decides to sue the surgeon because she didn't like the way her scar looked Surgeon's attorney will say there were 50 people in that emergency room. Dr McClure was operating on 25 of them By himself because he's a super doctor. So if the scar on patient number 10 was a little longer than patient number 11, under those circumstances that's really okay. That's not a big deal. So it's important to

42:18 understand the definition. You got to do something. Let's say you are at a meeting, so you're a church, and someone comes up and says you know, i've got this blah, blah, blah, blah blah and I've been taking medicine A or medicine B and I'm thinking about throwing out medicine A and just taking medicine B. Do you think that's okay, dr X? So what should Dr X do? True true, never was should not answer the question, but at the very minimum is to say I don't have enough information, which is true. I wanna think I should tell the young doctors coming up don't make telephone diagnoses. People will call you up and say you know, i just woke up and I got this pain that's on the right side and it's going around to the disc and to the that. Do you think I need to go see the doctor? or just wait until morning And I would say do the safest thing, and that's probably go into the emergency room. But you don't know, you don't have a clue. You don't have a clue. Now, this is based on what's reasonable for the reasonable position. The standard is not the reasonable person, the standard is the reasonable position. So what they will do is that they will call in a expert doctor, dr Rebus, and say Dr Rebus, we want you to review this record because there's been a concern

43:50 about DrX and we want to make sure that you think that he did or did not operate reasonably under the circumstances. Okay, so, therefore, elements that plaintiffs counsel has approved to find reliable for malpractice Did you have a duty to the patient? Did you have a duty to the patient. Now, if the patient came into your office and you touched him, then you have a duty. If you saw the patient in the emergency room, you touched him, you have a duty. And I say you're at a dinner party and you're all drinking your sodas. Exploders. Cold, cold, whatever you like. You're getting the charm. You're getting the charm.

44:36 You didn't even miss that event And you're drinking your sodas and someone asks you for advice. Do you have a duty to that patient? Probably not. So my point is. My point is you got to have a duty to the patient. Did you breach your duty for the patient? Second element breach means did you violate that duty? That's why you called in the expert witness to review the record. It was gonna be another doctor to say, yeah, he did. It did not breach your duty. Did your breach cause damages? And indeed were there damages. So the four elements that plaintiffs counsel has to prove before you can be found liable for medical malpractice. Now, if you are inclined to find out more about this subject, there's an expert, expert, expert. No, it's not One of the things that I would give. I talk to doctors and I would give basically the same talk to the doctor. There are certain things I would tell them, and I'll summarize it like this that I would tell them most patients will forgive you, even if you make a mistake. They will. I'm telling you they will after 50 years of practice they will. Most people will forgive you. They'll say, doctor, blah, blah, blah, whatever, whatever.

45:59 And they won't even think about malpractice as soon. But there's one exception And that exception is if you are injured. If you are injured D-E-R-P, they will not forgive you. If you walk into the room and wife is the patient, husband standing in the corner you ignore him. You just talk to her. You ignore him. Or the family or the grandparents or whatever. I'm just making this up. You ignore them in the room. You're disrespectful. One of the hypotheticals I used to use in my presentation to the doctors patient comes and see the doctor . Patient said to be Spanish-speaking only. Nurse gives a chart to the doctor and as the nurse is handing the chart to the doctor, the nurse says Spanish-speaking only.

46:44 Doctor says okay, doctor doesn't speak Spanish. There's a patient in the room. Doctor goes into the patient's room with the nurse who interprets for him and does his exam and history and all that sort of stuff, writes a prescription for the patient, okay, and before the doctor leaves the room he turns to the nurse and makes a comment about the patient. Quite common , real quick comment, but it's sort of a disparaging type of comment. Not anything, rude, rude, but it's not nice. It's not a nice comment. I'll put it like that, and one of the things that I always tell the doctor. I said I don't care what the language is and I don't care what the nurse tells you. I don't care what language they say the patient speaks, or the patient speaks to everybody who is said to be Spanish-speaking, and you can fill in the blank with Spanish. You can put it into Gaelic, mandarin, cantonese , on and on and on and on. Speak from English, so you do not have to speak the language to communicate. for a kind for the patient, i said so don't make stupid mistake, right? I mean, in my mind that's a stupid mistake or whatever, but there's no excuse for that. And it goes back to respect transcends all culture. Be respectful, just be respectful. Same thing your mother and father taught you when you were growing up be respectful. So I would always

48:16 end my presentation with the docs by saying don't be a jerk. Real easy to remember, just don't be a jerk. In summary, transformation in healthcare is patient-centered. Obama was a landmark healthcare legislation. Hospitals are achievement high reliability with link six and similar types of processes. Respect transcends all culture and avoid medical malpractice by not being a jerk. My basic principles is I always like to end up, god is in charge. I don't have bad days, don't sweat the small stuff, and most stuff is small. Forgiveness really is therapy and everything, everything, everything is a relationship, mutual respect, mutual trust, good communication . Are there any questions?

49:06 Speaker 3: Yes, Yes, we were talking about. It was a good question. Ha, ha, ha ha. Speaker 4: When you were talking about you doing things black and white and the way let's say, if I'm your patient, are you nice with me because of the way you think, or because of the privilege that I have, or the law? Speaker 2: Excellent question. I am nice with you because you're human And that's all you need is just to be human And all that other stuff. I completely agree . Go ahead.

49:50 Speaker 4: So there is no law, in other words, to tell you to respect the other. Speaker 2: There is a law, and that's an excellent question. I'll tell you why, because what we know is there are laws and then there's how you interpret. There is a law that says I need to treat you reasonably and responsibly. But a lot of times individuals can sort of do what they wanna do and sort of get around the law. But yes, there are rules that say I'm supposed to treat you a certain way. But a lot of that depends on whether I think I can get away with it or whether I think you will tell somebody, et cetera, et cetera. But the right way is it shouldn't matter that my approach should be the same as it is with everybody else, and that is with absolute respect.

50:49 Speaker 4: And just to finish it up, this is not a question, that's a question. When I went to the office, the doctor's office, i saw a sign that said don't tell me, why'd you Google on your symptoms? Speaker 2: Oh, my God okay. Speaker 4: So why is that a problem? Well, why is that? Speaker 2: Okay, i would consider that rude if I were a period, because what he or she is saying is I don't wanna listen to you. But the reality is, and I think this is a good reality. Yeah, there are bad things about the internet or AI, whatever it is, but I think the good thing about it is that it's an harrowing patient. It used to be that we control all the information, but now you can do a check bot or you can go online and you can look up anything that I tell you. So what I would interpret that is that they are interested in listening to you. They just want to tell me what they want to tell me, and for me that would be a non-star. I go to another doctor because I wanna have a discussion. Now, if I'm just a patient I'm not a doctor I at least want you to be able to explain to me what it is you're gonna do in plain English. Don't use all those big words to try to impress me in plain English And just like that HGAP question that I can understand. So it's the patient's perspective, not the doctor's perspective. And if someone was permanently putting stuff on the door said don't

52:26 even come in if you want me to ask a question. I'd pass them Because I would consider them rude. I would consider them And they already telling me they don't wanna talk to me, they just wanna tell me what to do And I'm not interested in that kind of thing. If I have the option, if I have the option, i pass them. I'm saying yes, sir, please go ahead. Gary, oh, can you hear me? Speaker 5: Yes, I had a question about what's the word. So, if there's a question of mild practice or anything like that, what is the statute of limitations as far as time period? Speaker 2: I think that's a good question. I think it's about that's a various per state. I wanna say it's like a couple of years, but that would be a good thing to put into Google and say it's now practice statute of limitation And they can tell you exactly. But I think it's at least probably about a couple of years.

53:19 Speaker 5: Okay, and the B part to that is how would you then, if you do have a suspicion, how would you then acquire the information as far as what happened or what took place? Excellent question. Speaker 2: Excellent question. I think the first thing you would do is that you wanna talk to an attorney. So then the question is well, how do you find an attorney? There are a couple of ways to do that. One is if you know friends who know an attorney. But the answer is most people don't, quite honestly. And what I would do is I would get, i would go back to the search and I would put in a medical malpractice attorney is near me, medical malpractice attorney is near me. I would call them up and I would say I need a consultation on a possible malpractice case. Most of the times they'll give you a consultation about 30 minutes, 45 minutes and ask what their fee is And then you can shop around to make sure that fee is compatible with what you're willing to pay. And go in and talk to somebody, because what you wanna do is you wanna present the facts and have them use their legal expertise to let you know is there anything there or not. And for a lot of people, just doing that is therapy. You know a lot of people are not interested in that, but they have a question.

54:35 You know they're uncomfortable, they say I'm not sure. And just getting legal advice sometimes is worth it, but that's the way I would do it. Speaker 5: So does the hospital. Do you have a right to information? as far as that, as far as a release of information from the hospital or doctor? Speaker 2: Are you saying information about the hospital and about the doctor from the hospital? Speaker 5: Yeah, as far as your possible question, as far as what happened in a particular situation, does the hospital have a right to release information to you based on that situation? Speaker 2: Okay, the hospital has a right to release your information. If you say I want my medical records, or let's say , if it's a child, i want my child's medical records, then that's within your right. The hospital is not gonna tell you much else other than that because they have their own attorneys and the physicians have their own attorneys. Now you break up a good point that I think is important to emphasize . Every hospital has a complaint department. If you have a concern, you can put it in very general terms and say I was in the hospital blah blah blah, or my chairman blah blah, blah, blah blah and we didn't understand why blah blah blah happened. Please explain. You can write a very generic letter like that. The important thing is that when you do a complaint, it has to be in writing. Most people don't know that You can't just call up and talk to somebody. You have to put it in

56:07 writing. One of the things that we used to do when we did evaluate at predational hospitals is how they deal with complaints in writing. They have a timeframe that they have to answer you specifically. So put it in writing. It doesn't have to be very long and say we have some questions about our case. We want more information. Mard hospitals will be very happy to talk to you about it. Speaker 5: Thank you. Speaker 2: You're welcome Any other questions? Speaker 6: Yes, Yeah, regarding that, usually if somebody calls in, they have some symptoms And not to give, what is it? you tell them Port of America or go see a doctor. And now sometimes, when you want to make an appointment at the hospital, they say, well, we can give you online at such a time if you want to know what's wrong with you. Is that something that is going to be or is that something that is just that hospital?

57:08 Speaker 2: Well, that's something that's happening right now And that's fine, Because what's happened is that now doctor of patient hospital in reaction is being virtual or in person That is perfectly OK, Where you put in your basic symptoms and then they'll ask you some questions And what they're doing is they're trying to decide is this something they need to have them come in for Or is this something that they can answer for you online? That's the best way to be quite honest Absolutely, Absolutely. Speaker 3: Yes, lauren, just mentioning that they can also risk the very expensive. Speaker 2: Excellent point. Excellent point If it's sort of like a relationship that's about to go bad in a way, you see them saying I'm talking about doctor of patient. There it is reasonable to say, doctor, we have a lot of questions about what happened to my uncle that you took care of. It is smarter to ask to meet with the physician for number of reasons.

58:12 If he says no, that you want to make a note on him. But a lot of times, to Lauren's point, this can be resolved just with a quick conversation. Most of the times there are questions that have not been answered or have not been answered completely, And just by getting those things answered all that stuff can go away. I would argue more than 50% of the time. It can go away if that position is willing to talk, Because the position, in my opinion, is more important than the hospital, unless it's a possible related employee. Even then I would still start with the position, Because you want to get that position on your side. If it's this oh, you're exactly right, There's no way blah, blah, blah should have done that, Then that's important for you to know. But excellent point, You want to have that meeting first, Because a lot of times the hospital will put together a team to meet with you , But it's always better to have the meeting first. Have the meeting first, Absolutely Yes, sir. Do you have a question? I'll let you Any other questions .

59:15 Speaker 5: Yes, sir, Yes Dr, Oh, yeah Well go ahead, go ahead, william. Go ahead William. Speaker 2: Runsilkram. Speaker 5: I'm sorry. I was going to ask. So if you have a current doctor that you're not exactly gelling with right So let's say you feel like the office is always in a rush, your appointment is kind of rushed through and stuff like that How do you go about getting another doctor as far as OK? so you call your insurance, you get a list of whatever. Are there certain questions that you should ask those doctors when choosing a doctor? What would you say is the best process of doing that?

59:57 Speaker 2: I personally think the best process of doing that is actually being there physically, if you can, because I think you're going to pick up some things that may not come up in a normal question. You're going to look around the office Is it clean? Are there a lot of people? Are there a few people? You can certainly still ask questions in terms of what their experience is. Let's say, if it's a procedure or whatever, you can ask some basic questions . But I think, if possible, make an eye contact. Doing that person-to-person type of thing is worth doing, one of the things that my wife and I do. We tend to do things differently sometimes, so I'd like to always help her with me, or vice versa , because she's going to pick up stuff that I'm going to miss. Well, i may pick up stuff that she missed. So I'm a big believer, if possible now, to have that in-person type of thing. If not, you can certainly ask certain basic things about procedures in terms of how that person explains things to you or if they're even willing to talk to you. All those things are things that you can sort of check the boxes in terms of pro or con or others. The other question.

1:01:11 Speaker 4: I think, yes, i think I'm one of those persons that you said, that I think the physicians are always busy And unless I don't see some openness , i won't even ask about what I went for. I'm just waiting for them to tell me. But you're a doctor over here And we usually tend well I'm usually tend to know his doctor and he's not a simple doctor, i mean he's a surgeon, oh man I have it with me. So when we approach to you, if we do and we engage in a term of a conversation, do you or your duty to that person under the regulations, medical regulations? Oh, I see, OK.

1:02:00 Speaker 2: It depends. I'm putting it on the hand, no, because it depends on the circumstances. Are you in my office Or are we in the No, we're here in Park lot. Speaker 4: Well, in Park lot, ok Yeah, in the field lot then there are probably no obligations. Speaker 2: But I'm going to go back to your original comment also In terms of because a lot of I would say 50% of, not more people are exactly like you, i would write down the question, because what that does that helps to slow you down. You can just say I just have a couple of questions And I wrote them down , is that OK? And you just go down your list. That way you don't have to worry about getting flustered and trying to remember And I'll just write down two or three questions that you have. Now, if it's at a social event, many times the doctor is not obligated to say anything, but that's on her what she says and doesn't say, and what I do. I always reply because I think it's really not to type. You know what I mean, but just say well, i'm not sure, or refer I use just refer to the primary doctor.

1:03:10 Speaker 4: Because there are persons I mean I work for the medical team management in the hospital There are people who know who they're looking for. Yes, A girl, a gap, good to get, Just to get that person or that hospital. Yes, yes. The same. Speaker 2: There is no question that if one has an addiction, then a lot of it is intentional, where they're strategizing and that sort of thing, that I view them as a subset as compared to just a regular patient. But having said that, one of the things that we dogs have to be careful of is assuming that one is acting a certain way to cause addiction, and one of the things I used to say drug addicts have pain too. They have real pain too, and just because one is a drug, that doesn't mean it doesn't hurt. And so we have to make that separation, because it's very easy And I've seen this in the hospitals a lot , oh so, and so is the blah, blah, blah, blah, blah It doesn't really hurt, it doesn't really hurt. Of course it hurts, of course it hurts. And I'll end on this The whole thing about health care disparities is where we look at people a certain way and then come to conclusions about them based on how they look And nothing to do with science just based on how they look, and that's like the worst form of health care disparities. But there's no question, there are people who are manipulative, usually addicts. People who know the

1:04:41 system know it very well. I've been doing it for years and know how to work the system. Most of them are going to be in the minority, except it might be a drug addiction clinic where addiction is the primary issue. Speaker 3: Yes, do you think there's a span on the way about how a person can deal with their natural physician, how they can go through their insurance from the end post-imperial to the end of the session, and it's really fine? Speaker 2: That's an excellent point, thank you. One of the things that we all know is that it doesn't always work. Nobody's fault, not the doctor's fault, not the patient's fault. Your insurance company can certainly help you with that. Just say well, i went to see Dr Chalktop and I think I want to go see Dr Collins. He seems to be a nicer guy, he has a pretty watch, and I just think I want to go sit here And then it's your insurance company that will accommodate you Because, remember, it's patient-centered. Now the Lorrainez point 50 years ago they'd say puff, chalktop's, all you have. But now you do have that leverage. And I would clearly encourage you to say it's just us or whatever. We just want to get a second opinion. But you want to explore that. You don't want to be uncomfortable all the way through. When you go into health care And you know from day one it's not working And you're not

1:06:12 communicating, you don't trust the trust, whatever, you don't have the feeling, whatever that is, then you want to get out of that before they even start, because it's not going to get better. Speaker 6: Yes, I would say, we should do that OK. Speaker 2: How did you do it? Speaker 6: Online. Online is a product doctor And when I needed a disease. I was able to change it. I had to get a first But, jamie, if it was not, i would have aligned and looked for someone else, and this thing I could do. Speaker 2: There you go. Yeah, and that's an excellent point That you have power, which is a whole bunch, and part of your power is that you can say no, that's like we talked about in other lectures. And part of your power is you will say I want another opinion or whatever. But I would encourage you to do that, and it doesn't mean you're a bad person, it doesn't mean the doctor is a bad person, it just means it's not working.

1:07:15 Nobody has to be at fault, but you have the authority to change that. Ok, all right, thank you. Thank you very much. Have a great week And happy Mother's Day to all the mothers. Speaker 1: Thanks for listening to the Healthy, wealthy and Wise Podcast with Dr William Chokdough. We hope you enjoyed this episode on health care's quality revolution, and if you found this episode helpful, please subscribe to the podcast on your favorite podcast platform. This will help ensure that you don't miss any future episodes And then share it with your family, friends and or your coworkers. Well, thank you for it, and we thank you once again for listening to the Healthy, wealthy and Wise Podcast with Dr William Chokdough. Live your best life the best way.