Hi! I am a big fan of your videos and a bigger fan of what you're doing with healthcare. We desperately need a healthcare model in which both patients and providers can be happy, fulfilled, and well taken care of- our current system is killing patients and burning out providers (as you obviously know). Plus you're funny as shit.

Two questions: 1. Any plans to reproduce Turntable in other areas? Dallas would love to have you. 2. How do Registered Dietitians fit into your team, or do they? I love seeing how much you as a physician value the other members of your healthcare team, but I've never heard you mention dietitians. Dude. I'm starting to feel a little left out.

Thank you for doing this, and especially thanks for everything else you do.

Dang, thanks!

1. Yes, via our partners Iora Health this model is expanding in multiple states, and actually Dallas is on the list.

2. The dietician question is a complex one. Our health coaches provide practical high-level dietary advice as well as teaching cooking/nutrition courses in our teaching kitchen. We refer to dietitians for more complex situations given their specific expertise.

Wow, I'm actually surprised to hear you refer out for medical nutrition therapy, but I can see how that makes more sense than having to keep a variety of specialist RDs on staff. I'll admit it bums me out, though. I'd love to see at least one very well-rounded RD on the team.

If I may ask a follow-up question: how can I stay in the loop on the timeline for Iora in Dallas? I'd genuinely like to be part of this. I have strong feelings about good patient care and provider burnout, which is why I'm in private practice. That said, I'd jump at the chance to work with you or at least within your model.

Check out http://iorahealth.com/careers to see where they are hiring and to keep in the loop!

Curious, what are your health coaches teaching for better glycemic control? Moderate carb intake? Low carb, high fat/protein? Something different for everybody?

It's really dependent on the patient, as you suspect.

ONE more question, promise. This shit is fascinating! What is the significance of having non-clinician health coaches? Do patients find them more relatable, or something else?

We think it's key. Non-clinician coaches speak human, relate to patients really well, are less intimidating, and are well equipped to focus on the blocking and tackling of developing a trusting relationship with the patient. This actually really helps drive behavioral change and frees the doctors to practice at the top of their licenses.

First, YOU'RE AWESOME!!!

Any advice for third year med students?

What is your favorite part of your new healthcare initiative?

Shucks, thanks! Advice for third years: you may think you are alone in your class in terms of feeling overwhelmed, depressed, or incompetent, but understand this fact: almost everyone in your class feels the same and they just ain't sharing it. Third year is exciting but also terrifically stressful and overwhelming. Don't despair!

Re: Turntable Health, the most exciting thing is seeing how the future of healthcare (Health 3.0) is shaping up to be the most exciting change, I think, in the history of medicine, a shift to personalized, relationship based medicine empowered but not enslaved by technology.

Hi Zdogg!

I don't mean to sound overly critical, but in looking over the public materials I can find on Turntable Health it looks like:

A monthly subscription premium in exchange for primary care, without an actual health insurance attached for pharmaceuticals, lab testing, specialty care, etc. It does seem to include some nutritional/exercise counseling - a service available to most PCPs that take MA plans and the like, where any value-based plan attempts to provide care coordination, social work, etc. for their patient roster.

Essentially, this looks like little more than the low-fee concierge medicine practices that have been springing up everywhere, for the folks with the disposable income to afford a monthly premium on top of their health insurance costs.

Can you help me understand what sets Turntable apart from concierge practices - what makes it more than what I've described above?

Thank you.

Great questions. The differences:

1. In addition to self pay, there are institutional options which allow Culinary Union members, Nevada Health COOP insurance holders, and employees of certain businesses (large and small) to get access to us for FREE (through their insurance, union, or employer). This allows us to see people of ALL income distributions.

2. The difference from "concierge light" is the team-based population management approach. Health coaches, LCSW, nurses, docs, working together, huddling each morning, managing the riskier patients actively through leveraging tech and human relationship to KEEP PEOPLE HEALTHY, rather than focusing on treatment of disease.

3. Incentives: because of those large entities holding us accountable, we give patients the care they need, not necessarily the latest scan or the care they THINK they need. Tough love and accountability are baked in, whereas in concierge it's about maximizing just patient satisfaction to encourage retention.

I'm reading everything you say in your voice already.

That is clearly a sign of the Apocalypse.

Or you're just the medicals second coming of facts and amazing rhymes at the same damn time? You might be the medical Jesus bro...

JCMD? A boy can dream.

Also - be nice to your nurses on your rotations. MS3s rotate through surgery. If they introduce themselves and are kind to me, the circulator, they have now gained an advocate for them in a bit of a cutthroat rotation. I'm the one making sure you have a good vantage point and step stool to see, and getting you into see that liver transplant when your attending's cases have ended. ;) If you're rude...well, my scrub will probably tell you that there's no room to scrub in and I will conveniently forget to page you when the patient gets there. Whoops. :)

YES. Best advice EVER.

Be nice to the nurses! I'm doing an off service rotation now where the residents aren't nice to the nurses and it is so much harder to get things done than at my home institution. Definitely wears on people.

How can residents be SO FRICKIN' STUPID? Not being nice to nurses, apart from displaying a fundamental lack of normal human decency, is the most suicidal thing you can do. Nurses RUN THIS SHOW PEOPLE. They can help you learn, help you help them help the patients. The few times I've lost my temper with an intern has been when they mistreated nurses.

Oh I know this answer! Ego, ego, ego! The residents here ream the nurses anytime something goes wrong. Consequently, the nurses will take their sweet time getting stuff done for the team. I honestly don't blame them. No one wants to work with someone who berates them all the time. Maybe some people are used to the old school idea that doctors are the bosses for nurses and forget that nurses really run the floor and can make or break your plans.

I am so used to getting along with nurses (friended on fbook and I bring in brownies for the night nurses on L&D) that being at this hospital freaks me out a little. What do you mean, we don't chit chat with the nurses?!

Edit: when you're a fourth year at your AIs, don't forget that some attendings will ask the nurses what their opinion is of you. And when you're about to graduate residency, don't forget that nurses talk to each other and the place hiring you may have their nurse call a nurse at your institution for their opinions. Just a little tidbit for this time of year....

The nurses' opinion saved my a** during my third year clerkship evaluations (otherwise, I was too much of a wise-ass to my own physician team, hahaha). Can't overemphasize how important the entire care TEAM is.

I had a giant jerk of an upper level as a third year on Gen surg. Basically made fun of me for literally everything (my race, the fact I wanted to do ob, my height...anything and everything). I would go home and just cry every night. I'm working the OB/Gyn ER my first month of intern year and who do I see in the hallway? This guy (and his wife). I am getting nervous and tell the nurses what happened. They are insistent on accompanying me in the room and give me lots of encouraging words. I go in there and talk to his wife and do everything by the book. This guy goes "oh weren't you a student of mine? You graduated?" in the most patronizing tone. The nurse snaps back with "yeah she did and now she's one of the best doctors here" before I even have a chance to even turn around.

God bless the nurses and god save you if you piss them off.

THAT is dope! Actually my former intern delivered my first baby as well. I THINK I was nicer? Hahaha! Nurses rule (especially in L&D).

Not remotely close to being a doctor but a physician that I shadowed said to me "Happy nurses, happy life."

You said it. No argument there. True for docs and patients!

Nurse checking in to say thanks!

Thank YOU.

sigh I think I love you!! (Srsly, thank you on behalf of all nurses!!)

Aw shucks blushes

Double question. Are you looking at integrating clinical pharmacists into your care model? Did you find someone to transcribe your lyrics?

Clinical pharmacists: YES. We work with Roseman University here in Vegas to get resident and attending pharmacists into our huddle. Re: lyrics, I enter them myself into the videos as captions, but recently discovered Rap Genius and am beginning to annotate lyrics there: http://genius.com/artists/Zdoggmd

As a Family Doctor, I say thanks to you for showing the world that doctors are humans and we are as fed up with the system as the patients. I've quit my hospital employed position and am opening a Direct Primary care practice in January. It's hard to look at polished practices like yours and not feel intimidated as I get this started up while still cranking out the numbers for the hospital.
Question: What do you think are the critical factors to a successful DPC practice? The value adds like cheap labs, rads, meds? The lifestyle/wellness/massage/lifec oach? Or Can you make a go at it by providing that small-town country doc level of caring and service that's gotten lost as healthcare has become an industsy?

Hi, and welcome to the brave new world of direct primary care!

I think ours is just one model: very capital intensive and human resource intensive, but I think you can do VERY well with a single doc in a small town who practices relationship-based old school medicine. I really do. I think all the other value adds help, but really it's about directly providing amazing care that patients believe in.

Thanks for recognizing this, and for living it too. As an RN who works in hospice, I see patients who have seen 15 specialists and had multiple medication changes before they are given a terminal DX. At this point they don't even know who their primary MD is, let alone what all these meds are for. If these people had a relationship cultivated with 1 md, life would be very different.

Thanks for taking the time to work with your patients and educated them. Don't forget to encourage them to set up DPOA paperwork and establish their final wishes! Doctors are often afraid to talk to their patients about their inevitable death, and oftentimes it ends up leaving patients and families surprised/stranded by the time things change.

WORD.

Thanks. You opinion means a lot. Just the kind of boost I needed. I'll be kickin' it Old school here in New Hampshire!

Live free or die yo!

ZDogg! You're fabulous! Thanks for the laughs and your unwavering support of us nurses. What has the reaction been from fellow physicians? Do they appreciate your style and fun way to approach people about their health, or do you find it hard to be taken seriously by your colleagues?

Thank you for all that you do! Docs have been huge supporters, because they are so beaten down by this system and would love to get to a point where we celebrate the team and get to just provide great care without all the administrative intrusion. The hierarchical culture of medicine is changing and it's great to watch it from the front lines. There are always some docs and others that are resistant (they have a saying: medicine will change one funeral at a time...haha, dark, eh?) but change is coming and nothing will stop it.

First - Readmission (Remix to ignition parody) is one of my favorite parodies ever. And that's coming from a Weird Al Enthusiast. I thought it was awesome how you incorporated inside jokes/actual medicine/advice into it. It was like Weird Al at his best.

My question is how do you find the time to do it? I'm a second year who has been struggling mightily to maintain his hobbies outside of medicine and would love your input.

Looking forward to all your future videos and best of luck with TurnTable!

First of all, thanks for the Weird Al compliment, as a huge fan it's the highest compliment I could ever hope to receive. #Genius

Re: time, see some of my prior answers. It's actually totally doable if you're passionate about it. It also helps if you save all that cramming for the night before the test ;-)

I'm not even in medicine and I really like your videos.

That is high praise and I'm humbled. Thank you.

I just watched the EHR/Empire State of Mind song. It's hilarious. The Eminem/Rihanna redo is my favorite. What's next on the list?

Next up, It Was A Good (Call) Day: https://soundcloud.com/zdoggmd/it-was-a-good-call-day

Followed by In Da Lab (a 50 cent parody of In Da Club) and Rehab (an Amy Winehouse parody about Skilled Nursing).

Still waiting on fda regulators (Warren G) for nutritional supplements and herbals. Willing to collaborate. Interested?

Regulators, MOUNT UP!

We regulate all products invented by the industry. We're dang good too, but we don't look at most stuff on the shelf. Talk to your pharmacist if you know what I mean, ask the geek.

16 in the pillbox, one down the hole, these herbs are about to make some livers turn cold...

I lost it at the billing and ICD10 lines, I've been dealing with that for the past 3 weeks, LOVE it.

WORD.

I'm in college preparing to take the MCAT in April and am a total hiphophead. The stuff you do is awesome, I recently learned about your stuff from another pre-med friend. My question: if I spit a dope freestyle at my interviews do you think that would increase my chance of getting into med school?

Depends on the skool son! (any school worth going to oughta jump at that s**t).

Can you please do more Star Trek? Wrath of Dr. Khan was one of the funniest things I've ever seen. I make all my ER noc mds watch it with me.

Man, I would do that all day long and geek out. Unfortunately, as much as Wrath of Dr. Khan is one of my favorite joints, it just doesn't get that many views which saddens me to no end. Thanks for spreading the luv! http://zdoggmd.com/wrath-of-dr-khan/

So you're telling me no bagels?

Here we are forced to do rectal exams...with no gloves.

Good morning Dr. ZDogg,

I'm a third year psychiatry resident (using a throwaway account) here in Las Vegas and have been following your videos for some time. Is turntable health planning on having mental health services in the future? If so, can I take a tour and grovel at your feet?

Tour anytime! [email protected]. We currently have a fantastic LCSW who helps with a lot of our mental health issues, but ultimately as we grow full psychiatric services would be tremendous (especially in THIS town, as you are well aware). Best of luck in your studies!

Love your work, found out about you in class during a lecture on palliative and hospice care.

• As there is an increasing need for physicians, many advocates for pharmacy believe that provider status and medication therapy management will be beneficial for improved patient-centered care. As a physician, what are your thoughts on pharmacy and medicaid part-B provider status for pharmacy?

I think everyone should practice at the TOP of their license. That only helps the overall care. So I'm all for it.

Can we invite you to give a Grand Rounds?

Sure, if I can pair it with one of my normal keynotes somewhere nearby at the same time (hard for me to travel for Grand Rounds otherwise given the opportunity cost). Thanks!

Dr. ZDogg,

As an IT worker in healthcare, your EMR video was hilarious. I think I heard a dig at one specific vendor as well... Can you say what EMR system you use at your company?

Our partners, Iora Health, had to build their own EHR that doesn't bill insurance, that's issue based, that allows non clinicians like health coaches to chart in the same note at the same time as doctors, and that patients can easily access. They don't sell it or license it, it's just to support our model of care (that we hope will spread). I used EPIC for 10 years at Stanford, and it is comprehensive and robust and also terribly painful and inefficient. Like most EHRs. Especially when the purpose there is to support hospital billing, compliance, and documentation but not necessarily patient care. We kinda need to change the model our EHRs are supposed to be supporting, right?

Love your videos! Your Not the way to die video is amazing! I am a CNA in a nursing home for several years now and have taken care of many people in there last days or at time of death. We as a society do not talk about death enough and it is great to see someone starting the conversation. My question is what inspired you to become a doctor? What motivated you to quit your hospital job and start a primary health clinic? Have you had any thoughts about spreading to more rural areas? I live in rural Idaho and it feels like we are always losing doctors but not gaining very many.

Hey, I recently spoke for a rural health conference in Boise, ID and so it's near and dear to my heart ;-)

I went into medicine to more deeply connect with people and also understand myself a little better. Burnout in our current non-system motivated me to try something different.

I'm an FP doc. I worked for Kaiser and burnt out in one year. My solution was to leave primary care, which still breaks my heart. Kaiser is great for patients but they work primary care docs to death. How does turntable differ? Smaller panels? Longer visits? And how do you balance giving pts 24/7 access to docs without that affecting the docs' happiness? I hated always having to still think about work at home. PS I love your stuff. Your Blank Script video is sadly too accurate. And I love that you're doing something different. I've been looking into these different models but when they all seem to be centered around pt satisfaction (yes, it is important), I feel like no one understands that primary care docs are people too and not just endless wells of giving.

Hi! I have a lot of friends at Kaiser, they are great on some levels but they totally overwork the PCPs without enough resources. We have much smaller panels (800-1200), lots of support from health coaches who do a lot of heavy lifting, EHR is easy and uncluttered, 30 min visits minimum on schedule with e visit options. They are indeed available but patients are quite good about taking care of most issues during reg hours (especially since visits are longer). One of our docs is a former burnt out Kaiser PCP actually and she loves it much more in this model.

Hi ZDogg,

Love your raps. Call day is my absolute favorite- "7am walking onto the unit!"

My questions are:

1. Will Dr. Harry be in any more of your videos?

2. What do you miss most about the Bay Area?

1. YES. It's just hard to coordinate since he lives in the Bay Area still. He has a big hand in many of our lyrics and ideas still though!

2. The diversity and the people! Otherwise, Vegas ROCKS.

more importantly, is dr. harry single?

Married, with kid. So yes, more or less ;-)

Your video made me laugh and cry because of the way healthcare is going. The hashtag #letdoctorsbedoctors is a statement I make all the time. I work with many doctors helping them learn their EMR and adjusting the EMR to help make their documentation easier.

How would you change things in Health Care to actually let doctors be doctors?

Thanks! The video to which you reference (for others' sake) is here: http://zdoggmd.com/ehr-state-of-mind/

Whatever we do to make healthcare better, it needs to be initiated by actual clinicians (doctors, nurses, PAs, NPs, social workers, etc) or we'll get more of the same. For EHRs, I think changing the fact that they are currently cash registers designed to support a bankrupt fee-for-service system is the fundamental problem. Coding/documentation/billing...if physicians could use the EHR to focus solely on providing care, and patients could read/write in their own chart, wouldn't that be something? That's why Iora Health (our partners) built their own software to support our practice model...it doesn't otherwise exist in the current EHRs.

I love most of your stuff (had mixed feelings about your end of life video)!

As an occupational therapist working in Neuro Rehabilitation, I'm curious to know what your exposure to therapy services are in the hospital and what you see in their role in treating patients in the hospital setting.

And also, have you ever ordered PTOT before? Or did you figure out that OT and PT are different services? :)

Hi, as a practicing hospitalist at Stanford for 10 years, I'm pretty sure I know what PT and OT are, and think therapy services are essential in most stages of patients' recovery. What were your mixed feelings about Ain't The Way to Die? (http://zdoggmd.com/aint-the-way-to-die/)

Hello Zdogg, 

You are awesome and your videos are great. All my friends who are nurses post them on facebook.

I was wondering what advice you have for someone who keeps trying to lose weight but doesn't get anywhere? I keep trying stupid fad diets and never get any traction. Fortunately no Type II DM yet but I feel it looming in my future if I don't get it together.

This isn't an easy question and very much depends on the person! Some respond to low carb approaches, others to low fat, others to mediterranean. I think the simplest advice is to lose most processed foods, eat at home rather than out, walk, etc. Sorry I can't be more helpful!

Hey ZdoggMD, huge fan of your videos. First of all, how's Dr. Harry doing? Second, I'm a high school student right now who is really interested in becoming a primary care physician (with a subscription-based private practice just like Turntable, though in a more rural area), and would really like to go to a combined BA/MD program, but my Indian parents aren't entirely on board. They believe that primary care is going to be taken over by nurse practitioners and PAs, and think if I really want to do primary care I should just go to nursing school. Do you think the role of physicians in primary care is going to be on a downward trend, and do you still think that being a primary care physician is worth it, in terms of money and overall job satisfaction? Also, what do you think about IBM's Dr. Watson and the potential growth of automation in medicine?-Thanks

Ah, I feel you on the Indian parents (haha)! Here's the thing: primary care owns the one thing that NO other speciality can really own in the same way or space: the human relationship. Watson ain't replacing that. As our PA and NP colleagues start to own the "precision medicine" space (that is, things that can be treated using clearly defined algorithms and processes), primary care docs by necessity will move higher up and own the very complex, relationship-based chronic disease management space. They'll be empowered by tech, by never replaced, IMHO.

You're terrific. Big time fan. If you ever need a Canadian guest MC/MD with mediocre flow rapping about the pros and cons of the system of your neighbo(u)rs to the north, give me a call. Or an experienced and board-certified GI to set up Turntable's endoscopy service. I'm cool like that.

I can be the heel in your videos also: "I'm the king of ass, there is none lower; sucker MDs, I'm a yacht-owner; to rule my kingdom, you must love odor; I won't stop scoping till you bend over".

Oh and a question: what's your favorite Nas track?

Much love from up north.

Mad luv to our 51st state! #BrianGoldmanJoke

Tight rhymes for a tight sphincter, me like son.

Nas? No comment.

Love it, let me know next time you are down in our 'hood.

Hi Zubin! First off, I'm a big fan of your work. Turntable health reminds me of the good parts of the healthcare system I participated in as an Army Medic. The whole wellness package offered to service members is something I really hope I can help bring forward to civilian healthcare as well.

Now I work as a tech in a busy urban Emergency Department and Trauma Center. I love the adrenaline and level of care, but I do find myself frustrated often.

My question is this - Do you have any tips for motivating those "regular patients" to seek more preventative care and lifestyle treatments? I genuinely want to help them, but often I feel like I'm barking up the wrong tree.

It's really tough in the busy ER setting. I think one thing is to accept them as they are, that they are the sum total of everything they've been through and applying our own values/expectations to them will invariably fail. I see humans now as these churning sort of weather patterns or storms (props to Sam Harris for the metaphor); they are the result of many forces, none of which are deeply in their control. So we can work to change the barometric pressure around the storm so it spins in a more beneficial course. Not very specific, but it's weird how this mental framework has helped me influence people more effectively, and also accept them for who and what they are.

Been a fan since I was in undergrad and you posted some of your videos on SDN back in 2010/2011. I've also come across your UCSF graduation speech a couple times while perusing the internet.

How do you seem to stay so positive and lighthearted in a profession where there is so much negativity and pessimism?

Awesome, you really have to forge your own positivity. I'm actually a person who tends to see the glass as half broken, let alone half empty. So if the path looks negative, creating a path you can believe in is the only option. That then reflects in a positive outlook (I'm so positive these days because I see the future of medicine as vastly brighter than the present)!

What advice would you give medical student graduates if they want to join a startup? Should they skip residency or do a residency first?

I'm biased, but I think you aren't a real doctor (with real experience and credibility) until you do some sort of residency. So my advice is, keep your startup feelers out there, but don't skip the residency!

ZDogg!! Thanks for doing this AMA! Huge shoutout to your latest EHR song.. your blank script song may have been on repeat in our residency clinic for a day..

How is Turntable Health progressing? Do you find that people are willing to pay the monthly membership fee? Have you had issues convincing insurance companies to help pay?

From what I've heard, your clinic sounds like such a great and innovative idea, with the focus on preventive care, coaches to help you cook better or exercise, but was just wondering how that worked out financially in our broken broken system.

You're a pioneer and I salute you. Keep up the good work!

Yo! Thanks for the luv, homie.

Re: Turntable, it has been a huge challenge to get payors to play ball and individuals to pay monthly memberships, particularly in Las Vegas where the environment for both is very tough. However, our partners Iora Health are growing this model in multiple states with insurance partners and so we KNOW it works. I don't think membership fees for individuals are the future though, but shared savings contracts with large integrated groups might well be.

Are you familiar with Dr. Ron Weiss, running the Ethos Health primary care practice in NJ? His work seems to have a similar purpose although with a different approach. Do you think there would be merit to combining these approaches?

Here's a link talking about his practice.

Will have to check this out later!

3: Can I still check out your facility if I ever come to Vegas? I know you have no need for an ICU RN. 😛

Of course! Email [email protected] and we'll hook you up with a tour.

If you ever open up a clinic in the Denver area, I'll be your first employee!

Our partners at Iora Health are indeed opening there! Check out http://iorahealth.com/careers to keep track.

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YES! Glad you like the glasses. In honor of Jay Z, they are Rocawear, purchased off Amazon for around $50 bucks each.

Fantastic stuff - clicked your link expecting to not be impressed (just because so many parodies are so terrible and inside-jokey) and was floored by how slick and meaningful your stuff is.

If you had to triage down to what you think is your single most important message to viewers / the powers that be regarding the state of healthcare in America, what would it be? Alternatively, what video do you think has the most impact to uninitiated viewers?

Yo thanks for the luv!

Distilled message: caregivers and patients are both sick in this broken non-system, and only these two groups working together can fix it. It may require a total reboot and rethink of how we do everything, but it can and will be done because the alternative isn't really an option anymore.

Video wise? I think Readmission: https://www.youtube.com/watch?v=aS3xaXsh6vo or Ain't The Way to Die: https://www.youtube.com/watch?v=NAlnRHicgWs are both pretty decent commentaries on the current state of affairs.

Dude, your videos are AWESOME! Been a fan of them for a while! Are those other physicians/nurses that you cast in the video?

What's your workout routine and how do you fit it into your day? Most of the physicians I interact with aren't quite built as you seem to be.

You're internal medicine, right? If so, can you branch out to EM without doing the residency or is FP the only option without doing a residency? What do you think about the growing need for hospitalists?

What's up with Dr. Ben Carson? Also, what's up with chiropractors hating on MDs/DOs? You should make a parody video on the latter.

Also, any advice for someone going into medical school with an infant son? I'm scared of not having time for my kiddo or fiancée.

Whew, lotsa questions. In order: 1. yes, mostly docs nurses and other medical peeps in my videos, filmed at our county hospital here in Vegas 2. I do the bare minimum to keep from getting morbidly obese. 3 days a week simple free weights (curls, benchpress, pull ups) and the other days run on a treadmill or use a stair master (I've set all this stuff up at home). 3. I'm IM. Can't really do a lot of EM without doing that residency these days. I think hospitalists are awesome (I'm biased). 4. Chiropractors, I'm not a fan. (the whole premise is quacky, although I do believe that we overmedicate and overmedicalize and overtreat in western medicine). I do believe the "laying of hands" is important for healing though. 5. Balance is ALWAYS possible, it will just be harder! (to some extent, your child will ground you, which is AWESOME).

Holy cripes! You responded! Thanks! In my area (the Midwest) there are practicing FP and IM physicians who will work in the ED on some days. I was just curious as I like what an ER physician and a hospitalist does but, I suppose, doing both would be impossible in major metro areas.

The majority of my friends in chiropractor school believe that everything can be solved with ROM manipulation and herbals/homeopathic routes. The biggest thing that irked me is they fully believe that vaccines can be replaced with a good diet that will bring about natural immunity. It seems to be that it is popular among chiropractic schools to demise and ridicule MDs/DOs for almost everything they do. Any clue why there's such a hate between the two?

Thanks again! Keep those fantastic videos coming!

The chiropractor thing is fascinating. Their antivax stance is a stunning example of their ideology (especially since most of them have benefited, like all of us, from the dramatic success of vaccines in preventing all kind of pestilence). I think all modalities have their place, and I'll try better to refrain from ridiculing them as they like to ridicule us. OK, I can't do it...they're ridiculous! (PS I prefer osteopathic manipulation)

There any way you see to breaking out of the bureaucracy and avalanche of new regulations that keep more folks from doing what you're doing?

How much do you think a poor primary education has to do with poor health? Is there anything you can see to be done about it?

(Last one I promise) - With all the technological advancements, and medical students (like myself) learning from online lectures (with some practical know how and patient interaction which varies by educational establishment) why isn't medical education taking advantage of these and cutting the costs of medical training?

1. It isn't too hard to step out and do your own thing. There are a ton of regulations but nothing that isn't insurmountable with some creative approaches.

2. Education is crucial to health. Although it's funny, those with a crappy education at least tend to get vaccinated, while hyper educated elite are the ones who are comfortable and affluent enough to take the advances brought by vaccines for granted and question everything. So it's complex! One key thing: respecting a given patient's level of growth and development means targeting our message to that level, in essence speaking the language that the patient understands without trying to drag them kicking and screaming up to a "higher" level. Much more effective that way.

3. Medical educational establishment is heavily calcified and tradition-bound. It will change, perhaps only with generational change (i.e., one funeral at a time...grim, no?)

Do you like Amateur Transplants?

LOVE them. Suman is a hero and early role model.

Hello! I'm excited you're doing this (and a huge fan of your music videos)!! How did you end up coming up with the idea of Turntable Health? How does Turntable health work with insurance companies (does it work with insurance companies)? And (excuse my ignorance), is it going to fit more with the pay-for-performance model that America is trying to adopt, or is it more rooted in the current FFS model we have?

Hi! Shorts answers:

1. Iora Health (our partners) developed the model: team based, leveraging health coaches who are non-clinicians.
2. Insurance companies that choose to work with us pay us a flat fee to keep their patients healthy.
3. We fit perfectly in a pay for value and shared savings model, we NEVER do any fee for service because we feel that that payment model incentives all the wrong things (episodic care, procedures, sick visits rather than prevention).

Thanks for the answers! I was looking at your website and your membership fees were low enough that I surprised (and impressed) that the system worked - involving insurance companies in a flat fee service makes a lot of sense!

Some totally unrelated questions:

-You're a celebrity in your own right...does that affect your relationship with patients? Do you find they take you more/less seriously, knowing that you're a not only a physician, but also a comedian and someone who is highly involved in a new sort of medical structure? It feels like it must be a delicate balance, and somewhat tricky?

-What are your thoughts about physician's roles in the media? There are some (very) famous physicians, like Dr. Oz and some presidential candidates, who have the potential to do a lot of good, but don't necessarily promote public health, health, and wellness the way that they could. What do you think public figures with MDs roles should be? Should they be constantly promoting public health/wellness, especially given the influence and scientific knowledge they have, or does it make sense that they don't necessarily use their fame for promoting evidence-based preventive medicine?

Sorry for all the long questions - it's just very exciting to be able to talk to one of the leaders in healthcare (and this seems like a very rare opportunity!)

Thanks for the questions!

1. Re: celebrity, I'm not nearly well known enough for my patients to ever notice...usually. When they do, they seem to get a big kick out of the fact that their dr. is a human being with an interesting "hobby" haha!

2. Great and complicated question re: fame/public docs. My limited experience in this space suggests that it is very complex. I spend a lot of time hating on Oz because I think he in particular MISLEADS patients with a lot of the crap he says (and because the contrast is so stark when he provides useful information: he's truly a brilliant and gifted communicator and shouldn't squander that). I think we take an oath to do no harm, but we need to also try to do as much good as we can.

Sorry for the short answers, my carpal tunnel EHR wrist is acting up!

ZDoggMD! I met you at the ENA conference. Thanks for coming!

What is one thing (or more) that you feel ER nurses need to do better at? What do we do awesome at that needs a shout out?

Yo! Thanks for sitting through my performance at ENA!

ER nurses ROCK at recognizing when something isn't right with the patient or their story (they are RIGHT THERE watching the dynamic) and so they are such a crucial piece of the care puzzle. BUT where they could improve (and where the docs could improve) is in working together as part of the whole care team to integrate this information. Breaking down some of the hierarchical walls in medicine is a necessary start!

How did you quit your job XD was it funny? I mean you ARE a parody rapper, so...

I went to me department chair and was like, yeah, I'm gonna have to leave because a fairy godmother came down and offered me a chance to stop just complaining about medicine sucking and actually go and do something about it. I think my team was thinking "Ah, he'll be back when he fails miserably." I think they are still thinking that, hahaha!

Hey! It's Terina and you know I've been a fan for years. Seems like yesterday when you moved to Vegas and we're trying to think of a name for Turntable Health. What a long way you've come! I could not pass up an AMA so here goes. 1:What's your opinion of mandated nurse/patient ratios in the hospital setting? 2: When is Dr. Harry having an AMA? Lol!

Hi Terina!

1. I don't know enough about the details, but I've always felt that staffing ratios (for docs and nurses and all in healthcare) are a key determinant of cost/efficacy/safety/burnout and so anything that makes the ratio more favorable is something I'd promote. In our clinic, we keep volumes down to provide better, more relationship-based care that ultimately saves money.

2. He's a social media illiterate! It's like pulling teeth with that guy, hahaha!

Thanks for the AMA Zdogg!! I posted this on your facebook page before but I'm a dietitian who grew up in the foothills by Clovis then went to UCSF for my dietetic internship! My parents just bought a house in Clovis.

1) RDs would love a few shout outs in future videos, FYI. We definitely have our gripes too. :)

2) Turntable Health seems to have a similar setup/goal to Kaiser (my employer). Is Kaiser a model for you? Is there anything you think Kaiser could do better/differently?

3) I get referrals often from hospitalists who want me to see their non-adherent CHF and DM patients who don't participate in our prevention disease management programs, then they're constantly getting readmitted for consequences of poor control. I feel terrible for them often because eating healthier isn't easy after a lifetime of poor habits. What do you think about the system of no reimbursement for repeat admits? Do you have any tips for persuading/motivating patients to improve their health?

As a Clovis native (my parents still live there), RESPECT.

1. Thanks! Stay tuned.
2. Kaiser is a great model, but the key thing is culture and focus on prevention (we have 30 min visits, every patient gets a health coach, etc) so it really is about decreasing downstream spend by getting prevention right.
3. Patients need to feel accountable to themselves and others. This is why we find our health coach approach is so effective. Patients really care about their coach (and vice versa) and so there is a sense that someone is paying attention and they don't want to let that person down. It's tough but it can be done!

Thanks for doing the AMA (wow, that would sound wrong out of context)! I've been a fan for a while and I'm just starting my first year of medical school. Any advice for books to read (with all my spare time) or resources to look at that would help change things for the better at the student/education level?

Read Sam Harris' book Waking Up (A Guide To Spirituality Without Religion). Or pretty much any book that gets you to look beyond your ego and sense of separate self and towards a more universal perspective. This will better equip you to get through your training and also will inform the "why" behind doing all that you will do.

Can you make a quick rap as if you are giving bad news to a patient?

I could, but I'd have to bill a level 4 New Patient visit and document that I rhymed the full 4 stanzas and then attach an appropriate ICD-10 code and fill out the "Bad News NOS" template in my cash register, errr, I mean EHR.

attach an appropriate ICD-10 code

Y93.D: Emesis due to Sick Flow

("Flow so sick make you wanna throw your food up")

Subsequent episode?

I like to mix lortabs with colors light, bad???!??!!?!!!

P.S. I'm a HUGE fan. #bringbackasiangrandma

Asian Grandma. I'm still in therapy over that. http://zdoggmd.com/bad-skin-taylor-swift-bad-blood-parody/

Hey ZDoggMD, I think your favorite work of mine was your commencement speech. If we lived in an alternate reality where you were able to change healthcare policy without resistance, what changes would you make? And any thoughts of how a PM&R training doc could be integrated into a practice like yours?

PM&R would be a great fit for our practice (so many MSK complaints addressed!). Magic wand: integrated healthcare system built from the ground up, local autonomy and self-management that allows adaptability, technology tailored for the integrated system, financial model that rewards value and wellness, medical education that was nimble, non hierarchical, and team-oriented. And some other stuff, hahaha.

Zdogg, love your stuff. I'm an EM physician so I especially loved your Les Mis parody of the confrontation between the hospitalist and the ED guy. How do you apportion your time between clinical medicine, speaking, and doing these videos?

Word up, that's one of my favorite videos. I used to be full time clinical (at least at the time I did The Confrontation) but now I split 50% business development for Turntable, 15% hospital inpatient clinical, and the rest speaking/making videos/being a professional jackass. In EM, like hospital medicine, some balance is possible due to the shift nature, but compromises are always required in any of this.

So is it really possible to be a physician and have a creative life? As in, do you really have enough time between both lives as they're both rather demanding?

I was working full time as a hospitalist and still cranking out ZDoggMD videos and songs. It's about efficient use of the time you have. And again, each side supported and fed the other.

Hey! I'm also an OT working in acute care, and my original question was already asked by /u/aishel (holla!).

However, I'm also a certified lymphedema therapist (CLT), so here is another question for you: A common issue we have in the lymphedema world is the patient who has gone years without a proper lymphedema diagnosis (after going from doctor to doctor and having all kinds of tests that turn up negative). Then they finally get referred to our clinic and they have already gone into stage III (terribly fibrotic, multiple infections, wounds, etc). After talking with multiple physicians, we have found that y'all just don't get enough education about the lymphatic system and lymphedema while in school.

So my question is, do you feel knowledgeable enough to recognize the signs of lymphedema in its earlier stages, and do you make referrals to lymphedema treatment clinics as part of your practice? If you don't feel knowledgeable enough about it, what is it that you don't know much about, and what kind of education would you find to be helpful?

Thanks, you're awesome!!

This is a great question. I think in the hospital medicine space, edema is treated often as an acute problem without a mind to longterm issues (including lymphedema). I think improved awareness at the medical student and resident level would help immensely so early education would be key. I could definitely improve in my own practice and understanding, as could many of my colleagues.

Yes, this is exactly what happens. I see many patients with "obvious" (to my trained eye) lymphedema being treated in the hospital with diuretics (can actually be detrimental to people with lymphedema). It happens so much that I've been thinking of doing an inservice about it for the residents and physicians of our two major internal medicine provider groups.

Thankfully, though, through tons of networking between our three major CLTs (me and two others) and numerous physicians in the hospital, the number of lymphedema consults we are getting, both in the hospital and in our outpatient clinic, is gradually increasing :) So that tells me that they're starting to recognize the signs and symptoms earlier on and are being proactive about it.

I feel like physicians like you who work in clinics that emphasize preventative medicine are key players in helping to stop the vicious cycle of lymphedema early on. A doc like you could play a major role in stopping the recurring infections and wounds early on by getting them into treatment. And I'm talking mostly about people with non-cancer-related lymphedema: primary/genetic, lipo-lymphedema, post-thrombotic syndrome, post-traumatic, and, oh god, the biggest one, CVI-related lymphedema.

WORD.

Hey Zdogg,

I'm a fan!

I'm matching soon and pursuing the hospitalist life after residency. Any tips to become a successful, happy, and well-rounded hospitalist? Where do you see hospital medicine in the next 10 years? Thanks!

Oooh, that's a long and tough question! The key thing in hospital medicine is finding the RIGHT job. There's a lot of diversity in the space, and the majority of the job layouts would cause me to quit within a week. So dig deep on that aspect (7 on 7 off? q4 call with residents? etc). Hospital medicine is going to get more and more data driven and precision oriented, trying to switch to generating value-based care over volume, so it's an exciting space to be in!

Thanks for replying. I just want to let you know that you're one of the few people out there that I feel tells it like it is but doesn't get all "the sky is falling" with regard to the changing face of american medicine. Your attitude pumps me up for the future of healthcare in this country.

MissionAccomplished. Thank you, actually, that means a lot to me! I'm really optimistic about the future of healthcare, we just need to get there by recognizing that it sucks RIGHT now.

i work for an offsite coding group for ED/ER and the "EHR" video... well, i'll be sharing that at work this week.

i saw you mentioned you're based in vegas - do you intend to focus there or try to branch out across the country, in terms of the information you share in your videos?
having been part of a patient's family ("ain't the way to die") as well as having giggles about the misspellings and homonyms present in medical records, most of what you say feels like common sense - aside from the parodies, how else do you push these suggestions?
what made you get into medical?
would you ever try to get together and do something with dr ken jeong?

What got me in is a long story!

But re: Ken Jeong...Ken, if you're listening, LETS DO THIS!

What are your thoughts on nationalized single-payer healthcare, and organizations like Physicians for a National Health Program (PNHP) that advocate for it?

I think payment reform without care reform (care model reform, team-based care, reform of our EHRs) is a necessary but not sufficient proposition. If we get the care model and approach right, then there's no reason to believe that a single payer system wouldn't work well to fund it. There's also no reason to believe that other approaches might not work as well. What DOESN'T work is a Canadian style approach: single payer funding fee for service with no care model reform.

Hi Dr. ZDogg!

Currently an M1 (who should be studying right now), and I constantly wonder what I should do for residency. My mind wanders to pediatric critical care, but fear encountering the same roadblocks you had in a hospital inpatient setting.

I'm trying to figure out how to pay down my huge med school debts in this field while coming up with a creative solution to the issues you see, while serving populations in the era of a PCP deficit.

My idea looks something like working part time in Critical Care, and possibly taking some of these patients into my fold of a primary care clinic on the side, which would be staffed with midlevels for most of the day. My questions are:

1) Would I need to maintain board certifications in pediatrics AND critical care? Or is that a given for anyone going past primary care into a fellowship

2) Does that seem like a sustainable business model, and in your healthcare system, Turntable, would a physician like me be helpful?

3) What do you want to know, or would like research to illuminate, in order to more effectively run Turntable?

4) Any student loan advice, or how to get rid of it ASAP?

5) How did you acquire equipment for studies? Leased?

Thank you so much for doing this, and your time!

Hi!

1. Not sure about rules for peds/critical care (out of my direct space).
2. YES, as part of a larger integrated approach which is the ultimate goal (Turntable is simply the primary care part of that)
3. Data on how to best promote behavior changes, especially in patients with chronic disease.
4. Take some financial courses! We docs are crappy at managing money, so everything you can do to learn more will improve your rate of payback and life in general!
5. I bought it used!

Do you treat lower income (below poverty level or close to it) patients at your clinic? And do you think it's accessible for them? Or are your demographics more middle/higher income patients?

Yes, definitely. Between our Culinary Union patients and our Nevada Health COOP patients getting federal subsidies on the exchange, as well as our self-pay uninsured patients, we reach deep in that demographic. It would be great if we could get a medicaid contract though!

As an MS1, I want to ask you this: what do you think the future of medicine looks like/what will be the biggest changes? I guess in terms of how physicians are trained (cost/length of training etc) and which specialties will see the biggest changes in the United States. Edit: Thanks for doing this! Also just putting it out there, I have a BM in piano performance and it's cool to know there are others in medicine passionate about music. Hmu if you wanna give some music to someone for a future jam.

Future jams are ALWAYS on the horizon so thanks. Re: predictifying on medicine, it's a tough and broad question but bottom line is we will start seeing a shift to Health 3.0 (a synthesis of the deep personal relationship from Health 1.0 and the evidence based/tech leveraged/patient empowered aspects of Health 2.0). More later!

What is your idea for ideal software? If you knew how to program and could make whatever software and change whatever rules, what would general practice look like?

You know, I think the answer is probably SO out of the box that it's hard to really even conceive of in terms of existing software and approaches. Some thoughts:

1. Data input interface needs to be faster than typing, intuitive, and seamless. (Google Mindreader?)
2. Patient contributions to the chart should be huge. Backstory, pics of families, important life events. We need to KNOW each other to really be able to provide great care.
3. Big Data made useful-->clinically actionable computer advice utilizing the reams of data we are generating these days.

Just some quick thoughts.

You rule. Love your videos.

This is a dumb question, but I noticed in your recent rap that your teeth look awesome. Do you recommend a certain kind of whitening treatment?

HAHAHAHA! Might be the magic of color correction in post production! I think my teeth err on the less than white side. No whitening although I do use a fancy Sonicare and colgate "whitening" fluoride toothpaste ;-) PS Floss yo!

I'm guessing the ama is over, but I hope you still see this. The US needs more of what you do. The young adults (18-25) in this country don't seem to know or care about the issues in the Healthcare industry, other than "it costs too much." Your music is a very familiar and comfortable way for people to start learning. The songs are great, and unlike other message oriented songs, they actually sound good. So often these kind of songs have the message as a higher priority than making the song musically good. Yours, on the other hand, is something I could see myself singing along with in the car. Well done!

Question, because apparently I can't just tell you that you're awesome, what made you start making these songs/videos?

Thanks so much for the kind words. I got into this for VENGEANCE! Haha, only partially true. I was so burned out in practice that making these videos was a cry for help, a way of finding a voice when I felt voiceless.

I just finished building my deck. I have been thinking I am putting on my last coat of varnish for the past three coats. Every time I finish and look back at the work I see dust and a couple of sags. Each coat is better than the last but, I'd like to put this portion of the project to bed. Is there any way I can sand or buff out the final coat and not end up with a low gloss finish? I tried hand sanding the last coat lightly with 320 then 400, followed by fine bronze wool and ended up with a matte finish. I was thinking just sanding out the couple of runs and sags then buffing out the whole thing with mirror glaze to get the dust bumps off, but I don't know if I'll end up with the same level of gloss after all that work. Any suggestions?

I say put it back in the garage, hit the local skate shop, by a preexisting deck and trick the f**k out of it! #SkateOrDie

I read your intro, then I watched your EMR video and I MUST meet you. My question to you is how happy are you with your medical biller(s)? Would you be willing to discuss outsourcing with my company to allow me the opportunity of working with you?

(Source: Owner of medical billing company for the past 14 years, been in medical field as MA for past 20 years, owner of patient advocacy company for past 9 years, love rap/hip hop, am generally cool but not as cool as you.)

Thanks, we don't do medical billing at all which is LIBERATING. Eliminating fee for service and coding and the like has saved us $$$ that we can put back into patient care (we are a capitated membership model).