“Having a physician partner who knows us well, who we can trust, and whose judgment we value exponentially increases the odds of accurately making the distinction between self-limited illness versus a significant disease process. This will also assist us in navigating the health care system such that we receive only that testing and treatment that is appropriate for our individual situation.

Just imagine how much better we would have fared in the U.S. had our individual responses to the COVID-19 pandemic been guided by trusted and qualified medical experts.

To make this novel partnership more feasible, I would propose at minimum an immediate 50 percent increase in the rate of pay for both adult and pediatric primary care physicians, thus encouraging more new physicians to choose those professions while allowing for more time for physicians and patients to spend together.”

Drew Remignanti is an emergency physician.

He shares his story and discusses his KevinMD article, “Only patients can save U.S. health care.”

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Rate and review the show at KevinMD.com/rate. Subscribe at KevinMD.com/follow.

Today on the show, we have Drew Remignanti. He is an emergency physician, and he wrote the KevinMD article “Only patients can save U.S. health care.” Drew, welcome to the show.

Drew Remignanti: Thanks. Thanks for having me, Kevin.

Kevin Pho: We’ll get into the article in a little bit, but first off, can you share your story and journey to where you are today?

Drew Remignanti: You know, I’ll start with the end. I retired in April of 2020 after 40 years of practice, having graduated from Rutgers Medical School in 1980. I can honestly say the pandemic did not drive me out of the emergency department; it just happened to be coincidental timing. I had become board-certified for the fourth time in 2014, and I did the math: The next time I would have to recertify, it was 2024, and I’d be 71 and probably a hazard to my patients. So 2020 seemed like a nice year, because it was a nice round 40 years.

Kevin Pho: So you mentioned that you’ve been an emergency physician for 40 years. Now, what are some of the biggest changes or trends that you’ve seen over your decades of emergency medicine practice?

Drew Remignanti: Certainly the biggest and most distressing is the fact that when I did my residency training, our faculty said you’ve got to get efficient, because when you leave here, you may be in a solo practice, a solo-physician emergency department, which, it turns out, I was, so you have to keep an eye on the entire department and how things are running so you don’t overlook something. So you have to be efficient. But the idea of being productive, the word they use all the time now, was never mentioned. So that’s the most distressing thing, because almost everything is based around the idea of getting people through faster and being productive. It’s an unhealthy emphasis, I believe.

Kevin Pho: I certainly see that word, productivity, in primary care, in my internal medicine practice, a lot. As it relates specifically to emergency medicine, what does it mean to be a productive emergency physician, in your eyes?

Drew Remignanti: They actually keep data on how many patients per hour you see, which is a somewhat useless number, because it depends on the severity of their presentation. But they just average it over the course of weeks and months and years, and they say that reflects what you’re doing. The problem is, if the pressure is to move faster, you’ll see more patients, see them more quickly, keep them satisfied, and get them out of emergency departments so you can move some more. I think it’s the cart before the horse.

Kevin Pho: Now, during your practice, how was that pressure relayed to you? Were you taken aside for meetings with the administrator and given spreadsheets of how many patients you saw per hour? How did that affect you when you were practicing emergency medicine?

Drew Remignanti: Yes, essentially every year, when you’re on your annual review, those figures and data were brought up, and you would be compared to your co-workers and where you fit. I remember, and I won’t go through all the details of it, but just briefly, I had a patient. My physician director said to me, “Try to pick up just one more patient at the end of your shift and boost your numbers.” So I picked up this patient, who had very minor complaints. I was about to send him out of the emergency department, and I asked him one more time, “What is it that worries you?”

“Well, you know what it is, Doc. I’m a hemophiliac. I’m afraid I’m bleeding in my brain.” That was entirely unrelated to everything else he had told me. I mean, I knew he was a hemophiliac, but there was no head trauma. So I reluctantly ordered a CT scan just to get that done, and sure enough, he had blood all over the right hemisphere of his brain. That’s the kind of thing that made me angry, because I would have missed that had I not made myself slow down a little bit at the end and asked that last question.

I told that story to my emergency department director, and I expected him to say something like, “Gee, that’s surprising, and I’m glad you work at the right pace, Drew.” He did not say anything like that. He went back to the productivity issue. I said, “Look, I have practiced to my own standard level. Fast things are fast, and slow things are slow, and it’s up to me to determine what I can move faster and what I can move slow.” It was a constant pressure.

Kevin Pho: From your experience, the people that are measuring productivity in numbers from the clinical staff, do they themselves have any clinical experience? Were they former physicians, or were they purely MBAs, administrative types?

Drew Remignanti: In the places I worked, they were all board-certified emergency physicians who, initially, before they came into administrative positions, were exclusively clinically practicing. But I think one of the fantasies of a lot of physicians in clinical practice is, “How can I get out of clinical practice and make similar or more money?” When they asked me for feedback about how I thought they could do their job better, I said to them, “You really need to be a clinician first and an administrator second.” I think they lost sight of that at more than one institution.

Kevin Pho: All right. Let’s talk about the KevinMD article that you wrote. It’s titled “Only patients can save U.S. health care.” Now, for those of you who get a chance to read your article, can you just walk my audience through it and share the story of why you decided to write it?

Drew Remignanti: You know, this is addressing the same frustrations. The people who are in a position to make changes, like the people in politics, the government people, are really not motivated to make a change, because most of them have gold-plated health insurance policies, so they don’t see a problem. They’re not going to worry about how they’re going to get bills paid. Hospital administrators, and those who can make decisions in that regard, are getting six- and seven-figure, or seven- and eight-figure, salaries per year, income per year, so there’s no motivation to change the system.

So, trying to retain some optimism, and I’m a reflex optimist, but trying to retain some optimism, I thought, well, you as a patient and me as the doctor, we can’t change the system individually, but together we could change how we’re going to operate. I think that gives us some power outside the hospital.

I put three links in my article. The first one references a study which showed, with hospital administrators trying to keep patients happy, that patients who reported greater satisfaction with their care actually had higher expenditures, more hospitalizations, higher expenditures for hospitalizations and drug costs, and, shockingly, actually had a higher mortality rate. It was just one study, and I don’t think being satisfied makes you more prone to die. I think what makes you more satisfied is getting more services, and more services can sometimes lead to complications, which increase your mortality rate.

Then the second link I have in there is to a hospital administrator, which people should really read, just to read that part alone. I have to admire her honesty, in which she frankly says patients need primary care, but they don’t need a primary care physician. So she was saying out loud the quiet part, which is: Hospital administrators are constantly telling you that service to the community, the value they’re bringing, and patients’ welfare are their top priority, and then they’re telling you things about increasing your productivity, which addresses none of those things. So she said out loud that patients don’t need or want primary care physicians, and we’re going to address their consumer-driven wants. So basically, they want to get the physician out of the equation, because by communicating directly with the patient, they can sell more services. So that was pretty distressing.

Kevin Pho: So let’s talk about patient satisfaction. Tell me how that influenced your career in emergency medicine. What’s the role of patient satisfaction when you are in the emergency department?

Drew Remignanti: Well, what I want is patient understanding of what I think we’ve identified as the problem. I want them to understand what we’re thinking jointly and adopt a joint plan on what we’re going to do to address that. Keeping them satisfied was really nothing that enters my brain when I’m talking to them. You know, the kind of things that satisfy people are getting seen more quickly, getting seen more cheaply, and getting rid of their discomfort. Of course, I’m always trying to address their discomfort, and I’m trying to be efficient, but that CEO is interested in patient-driven wants, not needs, and that’s a telling distinction right there.

Kevin Pho: Sure. Now, was patient satisfaction one of the metrics that you were measured for during that time?

Drew Remignanti: Oh, yes. There’s Press Ganey, which I’m sure you’re familiar with, the Press Ganey reporting. Basically, they ask a series of questions about your emergency department visit, many of which are about things that I have no control over: How long did you wait? Was the nurse treating you well? Those sorts of things, which I have no control over. But those things devolved into a number that was applied to me in regard to bonuses. Annual bonuses were definitely tied directly to patient satisfaction on the Press Ganey questionnaires, and also to your productivity.

Kevin Pho: Sure. Have you heard of stories where emergency physicians would let Press Ganey scores influence how they practice medicine?

Drew Remignanti: Everybody is aware of it. I think, indirectly, some of the colleagues I worked side by side with, I thought, made more rapid decisions than I felt comfortable with in order to get those better scores. Someone quoted to me once some feedback they got from administrators, that perhaps she should be a little more liberal with using narcotic pain medications, because that might keep the patients more content, which, of course, has led to our opioid crisis that we’re still in the midst of.

Kevin Pho: So when you hear things like that, that may be implying that prescribing more opioids may keep patients more happy, in hopes of increasing patient satisfaction scores, how does that make you feel?

Drew Remignanti: Well, it’s incredibly frustrating. The only way I was able to complete 40 years of practice was that comment that I made to my emergency department director: I’m going to practice to my own level, my own standard of practice. I never took into account how it affected my bonus. So you just have to practice to your own standards, I believe.

Kevin Pho: So what’s the path forward here? I’ve heard many of your issues that you bring up. A lot of physicians also bring up similar issues, and they propose a variety of solutions, but I want to hear from you. If you were in charge of our health care system, what would you do to solve these problems that you bring up?

Drew Remignanti: I often joke to my colleagues that if you gave me all the power and all the money in the world, I couldn’t solve our U.S. health care system problems. I don’t think I could, because I think they devolve into a one-on-one with patients. I think we need to become more involved, active, engaged patients, and that’s why I’m appealing to patients. I’m characterizing it as a partnership. You need to care as much about your health and your results as I do, and we need to work together towards a goal. You’re the expert in how you feel and what you want to accomplish. I’m the expert in: Is that a reasonable goal, and how do we get you safely there?

Kevin Pho: Now, what are some specific ways we can do that? How can we appeal to patients?

Drew Remignanti: Part of my strong feelings about this whole set of questions is that I was a patient for much longer than I was a doctor. I became ill with the chronic disease of ulcerative colitis at age 19. I had that all through college, medical school, and my residency training, and then multiple hospitalizations in regard to that, and that was all capped off by having a stroke in 1992 that was felt to be a coagulopathy secondary to my ulcerative colitis. I was out of emergency medicine for five years, from ’92 to ’97, and in that period of time I worked in occupational medicine and urgent care and did some community health service work as a physician.

So I can’t really speak to what you have to face as a primary care doctor, but I would consider, and this might be the failure point of my practice, directly asking patients to be as engaged in their health care as I am. I would give them the obligation of being mini-experts in the two or three chronic conditions that they have. I’d say, “At a certain point in one of our visits, I’m going to give you a pop quiz. I’m going to ask you what medicines you’re on, and you need to be able to give me the names, the doses, and why you’re taking them.” I’m sure I would lose a significant portion of my patients with that approach, but I think we really need to hold patients more accountable. I’d never tried that, because at that point, when I was in the community health center, I was trying to rehabilitate myself to emergency medicine, and I was dealing with a relatively unsophisticated patient population, which was an additional challenge.

Kevin Pho: We’re talking to Drew Remignanti. He is an emergency physician. He wrote the KevinMD article “Only patients can save U.S. health care.” Drew, for those emergency physicians who are still practicing today, and I’m sure that a lot of the pressures that you described are only getting worse, what pieces of advice do you have for these physicians today?

Drew Remignanti: It would be the same thing I mentioned a couple of times, about determining what your own standards of care are and practicing to that level of standard regardless of how it affects your employment, which is easy, of course, for me to say now that I’m no longer employed. But it was the approach I took during the last 13 years of my career, when I worked in a very busy hospital emergency department.

Kevin Pho: And if physicians wanted to push back about some of this administrative oversight, and I know specifically in emergency medicine you guys have some unique challenges with for-profit, venture capitalist companies purchasing the emergency department, which includes a whole host of issues, what are some ways that emergency physicians can push back about some of their loss of control over the profession?

Drew Remignanti: I still participate in an emergency medicine Facebook group called EM Docs, and there’s some conversation back and forth about whether we should unionize, as physicians in general and specifically as emergency physicians, to combat that multi-hospital group problem. I think it may come to something like that, where you actually have to be willing to put your job at risk in order to make changes, which is hard to do when you’re established in a community and have a family. It means being willing to possibly be fired because you’re a squeaky wheel.

Kevin Pho: When you talk to other physicians in this emergency physician Facebook group, what’s the general appetite for doctors in general taking that type of risk?

Drew Remignanti: I don’t have a good feel on the pulse of that. I’ve seen it bandied about, but I think, again, it’s understandable that people are not ready to get quite that aggressive, so I don’t see it happening anytime soon. Although, I saw an article come across my email about the Stanford residents. They’ve just recently formed a union in order to stand up for their rights. So it may happen, and it may happen at the training level. The interns and residents make the first jump, and then perhaps that’ll motivate the more established physicians to follow the same.

One quick comment: I’ve been doing a lot of research on these topics, so I’m hoping to try to create a book-length presentation on this, which is maybe a little bit of a pipe dream. In communicating with an agent recently, who already was representing a physician author and wasn’t interested in picking up another one, she said, “Gee, there should be a forum for physicians to communicate and see how they can address this problem.” I did write back to her, saying, “That’s operating under the assumption that we’re still steering the ship. We physicians are not steering the ship.” I think most non-medical people think physicians are in charge, and why can’t they make it better, and they’re making all this money. All the money that’s being made in health care is going to people at the administrative level, and it’s not going to your front-line physicians.

Kevin Pho: And my final question: What are some of your take-home messages that you want to leave with the KevinMD audience?

Drew Remignanti: I guess it would be: Try to take on the challenge with your patients to see whether you can get them to take more responsibility by referring to the interaction with them as a partnership. We are forming a new company, the partnership, and the subject matter of our partnership is your health. You have to be as committed as I am.

Kevin Pho: Drew, thank you so much for sharing your story, time, and insight, and thanks again for being on the show.

Drew Remignanti: Thanks for having me along, Kevin.