Dr. Mike Hoaglin - Medical Director of Prairie Health and Independent Telemedicine Consultant
We’ve talked a lot on Raise the Line about the upsides of the telehealth boom, but our guest today, Dr. Mike Hoaglin, brings a new silver lining to light: it’s one way to help with the physician burnout crisis. “I've certainly been in the trenches of burnout in the past, and having the flexibility to be able to see patients when I'm at my best and when I'm able to be at home with my family is just a great setup for me to be successful, and my patients benefit.” In fact, “Dr. Mike” was an early adopter of telehealth and other medical technologies as well. Best proof point? He and host Shiv Gaglani worked together a decade ago to develop the Smartphone Physical. Add that experience to his work in federal health policy, various start-ups and a stint as the clinical director on the Dr. Oz Show, and you can understand why “Dr. Mike” is full of revelations on many subjects including on a special focus of his, the microbiome. For instance, did you know your body has more foreign cells (bacteria, fungi, protozoa, etc) than human? As Dr. Mike shares with Shiv, intensifying interest in these trillions of microorganisms in recent years has led to a deeper understanding of the wide range of impact gut health has on overall health, from diabetes to mood disorders. Check out this lively excursion through a fascinating career, and be sure to listen all the way through for Dr. Mike’s advice on the one thing you should eat more of for good gut health.
SHIV GAGLANI: Hi, I'm Shiv Gaglani. My guest today has such a wide range of interests, experiences, and expertise that it's hard to know where to start. But perhaps I can sum it up best by saying that Dr. Mike Hoaglin is someone who pushes the envelope in medicine, looking for ways to make things work better. Among the points of interest, he was a very early adopter in developing a 100% telemedicine practice, well before COVID, and he advises startups in telemedicine companies in best practices. He's also been deeply involved in clinical applications of microbiome science and worked for a leading company in the space. If that were not enough, he also spent time as a policy analyst at the U.S. Department of Health and Human Services, and was Clinical Director of The Dr. Oz Show.
Mike and I go way back. We actually met when he was working for The Dr. Oz Show in Philadelphia, when he was running something called "The 15-Minute Physical," where he and Dr. Oz partnered to screen thousands of people through a 15-minute physical. We became really good friends and launched, at TEDMed back in 2013, something called a smartphone physical, which was adapted based off of that. It was a very early adoption of digital health technologies and doing a complete physical exam using smartphone gadgets. Mike, it's so good to have you on the show, finally.
DR. MIKE HOAGLIN: Great to be here, Shiv. Thanks so much for having me.
GAGLANI: Of course. Obviously, I know a lot about your background. You went to Penn Med. You went into Emergency Medicine. Can you give us a bit more background on yourself for our audience about what got you interested in medicine in the first place, and then how you've had such a wide-ranging and interesting career within medicine?
DR. HOAGLIN: Sure. I initially wanted to be a doctor all my life. I've always liked science and helping people, teaching people, but I got more into technology in high school and got the bug of bioengineering and ended up majoring in that. But once I started looking at some internships where I looked into working at a hospital and did some research with some surgeons, I was doing rounds with them and realized that I really didn't want to just make widgets, but I wanted to really help people using technology. I wanted to directly heal people so I decided to do med school, but still keep my foot in the technology space.
I took some time off before med school to work in management consulting with Accenture. At that time, it was really important to get everyone online everywhere. All the doctors and hospitals needed to be online with their electronic health record systems. That was the big thing back then. I spent some time in that space, as you mentioned, working for the government, coming up with policy to help doctors and hospitals adopt these technologies. I took time off from med school about three times to pursue my interest. So I really just followed the things that were interesting to me. I first worked for the government in health IT policy, took some time off to work for The Dr. Oz Show, as you mentioned. Then for my senior thesis in med school, I worked at another startup called Practice Fusion at the time, which is an electronic medical record for smaller practices. Now, I continue to maintain a clinical practice and still be involved in the health IT, digital health space as well.
GAGLANI: Yes. So actually going into telehealth, you were a very early adopter, I think, among physicians, back when telehealth companies were still trying to get people to use their services—when if a telehealth company could get 1% utilization among members of a particular insurer, it was successful. Obviously, COVID flipped that script. Can you tell us a bit more about what got you into telehealth and how you've structured your practice, and what the last two years of COVID have done to your practice, or telehealth in general?
DR. HOAGLIN: Sure. Telehealth is really an interesting thing. It's been around, in a sense, for a long time, if you think back to the early 20th century. There's been telephones, faxes, pagers, and all those things you could argue are telehealth. But it's really how we view it now and how we're using the technology we've had for a while to deliver patient care. I mean, we finally have people realizing that it allows the clinician and patient that flexibility.
I like to do a lot of different things, as you mentioned, as a lot of doctors like to do. I think telemedicine allows me to keep a variety in my career. I can see a variety of different patients. I can see patients all over the country and practice real medicine. So it's been a way that I've been able to make my life more flexible. I've certainly been in the trenches of burnout in the past, and having the flexibility to be able to see patients when I'm at my best, and when I'm able to be at home with my family, it's just a great setup for me to be successful, and my patients benefit. I think a lot of patients and doctors realize that quality can be delivered with flexibility and efficiency through telehealth.
The thing that I think really changed with COVID was the acceptance of telehealth. I think patients and doctors alike found that the pandemic unblocked our ability to see those patients that we couldn't bill. So, in other words, if you can't bill for something, then the healthcare system is probably not going to do it. So the the fact that Medicare relaxed certain in-person and documentation requirements that allowed telehealth to happen, it just overnight kind of became a thing. We went from, like 13,000 Medicare telehealth calls before the pandemic, to over 1.2 million in April of early pandemic. So it really was kind of overnight.
Patients saw how the sausage was made, to some extent, because they were seeing that telemedicine wasn't so bad. They didn't really have to go to the doctor's office to get a blood pressure check. They didn't have to park and wait in the waiting room just to get a refill of the medicine they take every day. The healthcare system is loath to change, and if you take away their ability to bill, they're going to change. That's probably the only thing that will get them to change quickly. I think that's really part of the catalyzation that took effect with COVID.
GAGLANI: Definitely. Some of that stuff will hopefully be permanent. It's very consumer-centric and hopefully some of the cost savings or efficiencies can bleed into the healthcare system. Can you paint a picture of exactly how you run your own practice? What does an average week in the life of Dr. Hoaglin look like as far as how you balance your telehealth patients, and what hours you're on? Do you talk to other physicians for consults here and there? I think our audience would be very interested to know what a real practice physician like yourself looks like.
DR. HOAGLIN: Sure. So I see two different sets of patients at this point. I have a panel of patients in my telepsychiatry practice that are my patients. I hold onto them, and I see them long term. I've had some of those patients for almost four years and they are able to set up time with me in between the times that I'm not on a shift for my other practice. I also do some tele urgent care, and in that practice, I sign up for shifts just like you would in an urgent care or an ER, and so I just see who comes in the door. I have a queue of patients. I see their chief complaint, and I do usually four to eight hours in a shift.
So if I do four hours in the morning and then maybe another four hours in the afternoon, I'll have a bunch of fifteen or thirty minute spots to fit in the psych patients in between. Those are usually 30-minute initial visits, and 15-minute follow-ups. Whereas my urgent care patients, which can be just about anything, are on average about eight minutes, they can be as short as a couple of minutes if they need something quick, or it can be up to 40 minutes if it's something serious. I set it up so that I practice both most weeks. I do about 10 to 20 hours of tele urgent care, and about 20 hours or so of telepsychiatry per week. Then my other time I spend consulting, working with other startups who are trying to set up telemedicine practices and companies. So, I certainly keep busy, but it's all stuff that I really enjoy doing. I still get a full night of sleep most nights.
GAGLANI: Yes, that's great. That's obviously critical. Burnout among clinicians, especially during the residency years, was very much top of mind even before COVID. COVID has made that a lot worse. Maybe you can spend a minute talking about that issue of burnout among the clinical population. Any ideas, apart from maybe adopting physician-friendly or practice-friendly things like telemedicine? Any commentary you have on burnout and how we can address it, so that we can not only raise line by training more healthcare professionals, but then keeping them in practice longer?
DR. HOAGLIN: Sure. Yes, burnout is an epidemic, as we all in healthcare know. I think there's a lot of different causes and theories as to how it became such an epidemic, but I think there are some things that are pretty clear. Medicine has become a lot less focused on the doctor, which I think is good in some ways, but it's led to a lot of unfortunate consequences. With the advent of patient-centered care, and making sure that pain was the fifth vital sign in the ER, and making sure that customer service from the hospital standpoint was high priority—which I think is a good thing—we kind of lost track of what the doctor's experience was. It's funny, because I was working for the government, trying to get doctors to adopt electronic health records back in the 2008 to 2010 time frame during Obamacare. But we're now realizing that although we tried to get doctors to use that technology meaningfully, the systems really came out of a need to bill better. The systems were designed for billing, and so doctors are caught up in all these billing requirements now that we have EHRs, such as there have to be a certain number of physical exam components, review of system components; the HPI has to talk about at least seven different things.
I think it's getting a little bit better, but for a long time, doctors were getting bogged down in billing codes and long documentation issues, spending a lot of time after hours that they weren't being paid for to write notes and answer patient messages. That was all in addition to what they were already doing, spending sometimes longer than they were on shift, doing notes. That just leads to burnout, or some will call it moral injury, where you're doing these great things for patients, but you have a low sense of accomplishment. You're feeling physically exhausted, like what you do doesn't really matter, because you're just sort of caught in this loop of documentation, doing what the hospital wants, trying to keep patients happy and healthy, and there's really no one that's looking out for you. At the end of the day, you're still an employee. If you're working for a hospital, or clinic, or working on your own. Trying to deal with insurance companies as a solo practice is also stressful, and having them tell you how to take care of patients.
Doctors used to have a lot of autonomy, and now we're finding ourselves to have a lot less, and practices being bought up by large healthcare systems. With all that, we lost track of the doctors, I think, for a few decades, and now we're seeing more doctors trying to get out of medicine. They're angry with each other. Administrators are having lots of rules that are basically tamping down any new ideas that the doctors might come up with. It's really become, in a lot of ways, a toxic culture. Just working in that, day in and day out, 12-hour shifts, and not really being appreciated or fairly compensated leads in a burnout or worse. Sadly, there's like, 400 physician suicides every year.
I think the wake-up call is maybe finally being heard. We're seeing a lot more conversation about burnout and moral injury, and it's not just doctors, it's also nurses, allied health professionals as well, who are dealing with all these stressors, not to mention a lot are dealing with life-and-death situations and seeing patients die on their watch. It's a lot for any human being, and I hope that now the telehealth has allowed somewhat of a relief valve for some clinicians who want to add that to their practice, or shift their practice to that, that these administrators and hospitals will come up with either more flexible work environments, shifts, schedules, having a more personalized schedule, since there are people who like certain parts of the day, or parts of the evening to work, and others want to work a few days a month.
I think coming up with flexible work arrangements is one. I don't think just having yoga and cookies every other Tuesday is the way to solve this. I think there needs to be an actual system change, where we go back to putting the clinicians first when we design new technologies. Doctors weren't really consulted that much, historically, when these EHRs came to be, so they're stuck using the system that wasn't designed for them. I think now, we're seeing a lot more doctors on the technology side. I hope that with digital health, things will get better for doctors as well.
GAGLANI: Absolutely. You have a front row seat to being able to not only work at companies, but now advise other companies that are working to add the physician voice and the patient voice into what they're building. Let's go into some of that, too.
What are some of the companies or trends that you're most excited about now? Also, maybe you can transition and talk a bit about the microbiome experience, because everything else was very heavy tech, and then microbiome—obviously, a lot of tech there, too—but very much going into hard-science-type work, direct-to-consumer-type microbiome work. You've done a lot of consulting for microbiome companies as well. Maybe bring us up to speed on what you're most excited about in digital health, telehealth, what companies you're advising and also the microbiome aspects.
DR. HOAGLIN: Yes. I think a couple things. One is that I think we're seeing a lot more of measurement-based care in various specialties. Even in psychiatry, which traditionally was very qualitative, is now becoming more quantitative. We're seeing that in diabetes care, and we're seeing that in obesity care and even surgery, where things are being measured longitudinally, more readily and with the technology that's now available, so that you can actually show objectively certain outcomes, seeing more precisely whether a treatment is working. We are seeing precision medicine being used more, even looking at someone's genetics, you can find out what medications might be more appropriate for them, from psychiatry and various other specialties as well. So, that's something that's definitely exciting.
I think worldwide, I'm excited about more of the world getting more access to the Internet, to be very basic. I think a quarter of the world, at least, doesn't have access to sufficient computers, Internet and email. So, I think that we're going to basically see the smartphone come full circle, and come back to the smartphone being the place where a lot of people in the world are getting their healthcare. I think the fact that we can take advantage of that technology, something that pretty much everyone in the world has some access to, is going to really bring healthcare to a lot more people.
GAGLANI: There are two sayings actually this reminds me of. One is Amara's law, which is, people tend to overestimate the impact of technology in the short-term, and underestimate the impact in the long-term. I mentioned this on the Dave Albert interview, a mutual friend of ours, who started Live Corp. It was that 2011 to 2014 period when we were doing smartphone physical, where digital health, telehealth, all of these things were very exciting. Remote patient monitoring, a lot of investment, but in that zone of disillusionment from 2014 or 2015, to 2018 or '19, even, where there was no Cares Act; there was no real incentive. The system wasn't adapted to change. Then, obviously, COVID came around and you had years of advance in a matter of weeks. So that's one.
The second is, if you stick around long enough, your timing is perfect. It's another saying I like to hear, where, Live Corp and many other digital health companies we know just lasted long enough for them to ride the wave that eventually broke, which is great for them. We knew a lot of really smart and awesome companies back in the day that were pioneering this. I think about the ZO Head, the ECG mask that people would wear when sleeping to monitor sleep quality, which was a wonderful idea. Technically, a little early, definitely early, and then kind of failed, but now there are so many new sleep tech gadgets out there. So super interesting. Is the microbiome in that space? Where do you see us with microbiome?
DR. HOAGLIN: Yes. That's such a good way to put it. I think it follows that exactly, Shiv. The time we were doing the smartphone physical, everyone was excited about it. There was the surgeon general, there were several celebrities that we got to do physicals on, as you know. Even heads of health insurance companies were excited. But then it kind of came down to the movement of information and HIPAA, which often comes up to shut things down quite a bit and I think HIPAA is often misapplied, unfortunately, sometimes as a way to just shut something down. It has one P and two A's. Do you what the P stands for?
GAGLANI: No. What does it stand for?
DR. HOAGLIN: You might think it's privacy, right? But it's actually portability. So HIPAA initially was really intended to get information moving, not to silo it, and clearly we've got to have encryption and protect transmitting patient data. But HIPAA is often applied in places where it's not even relevant. So, I think with this pandemic issue and the catalyzation of telemedicine and telehealth, the system is just more comfortable with moving patient data. Because, if we think about it, your smartphone is listening to you all the time. Alexa is listening to you all the time. You're in the doctor's office, so it's hearing you. So, privacy is kind of an illusion, to some degree.
I think the microbiome is similar. Back when I was in med school, it was kind of mentioned as something really interesting, and I was fascinated back then about how the gut bacteria—we called it the gut flora back then—would influence the body and digestion. Then you kind of hear about it for a while, but then there was this boom in the sort of the late to mid 2010s, that after next-generation sequencing came about, we were able to process a lot more data, a lot faster in terms of genetic data. We saw that as an opportunity to sequence the microbiome, which has trillions of cells all over our body, and in our body. There are more foreign cells, such as bacteria, fungi, protozoa, viruses, than we have in our own human body. So, there are more foreign cells than human cells in each of our bodies. They say that every time you have a bowel movement, you become a little bit more human.
GAGLANI: I never heard of that saying. That's hilarious.
DR. HOAGLIN: Now we're seeing a bunch of startups and companies, even pharma companies, very interested in the microbiome, because it is essentially affecting all the systems in the body from head to toe. With the right engineering, the number of therapeutics that you could think of is pretty incredible. I mean, they can already have a microbe make gasoline. So imagine if you had microbes making insulin or whatever molecule is missing from the human body. Right now, I work a lot with the gut-brain axis, of course, which is the fact that the gut affects our mood, the gut affects anxiety, the way that we view the world, in a sense, and we know that 95% of serotonin is produced in the gut. A lot of people are interested, and there's lots of companies looking into how to measure it and what to do about it.
GAGLANI: It's very interesting, just seeing how your career has evolved, where you're really at the forefront of both these areas, telehealth, microbiome, and working to combine them in interesting ways through the consulting work. Most of our podcasts are 20 to 30 minutes long; I know we could just focus on microbiome for at least an hour to talk about that stuff. I know we're coming up on time, so I wanted to make sure that our audience heard two things from you before you have to go. The first is, again, you've had a very interesting career path, going from healthcare and engineering into media, into technology, into hard science and microbiome work, government policy. What advice would you give to people starting their career in healthcare right now, meeting the challenges of the COVID moment, and getting involved in tech? What things would you like them to to know, or what would you tell a young Michael Hoaglin, too?
DR. HOAGLIN: Great question. I would say that, as cliché as it is, that you should do what really interests you. I think sometimes we get caught up in doing things that we think that the next step in our life wants to see that you've done, or that you do. But if you do what really interests you, truly, and draws your attention, then you will naturally talk to the right people, research and study and read the right things, and use the people that you know in those communities to find those opportunities to work for a company in that field, to work for someone in the government who's in that field.
Just as an anecdote, to work for the government at a really exciting time when the HITECH Act was being written and executed. I saw on the news that Dr. David Blumenthal was being appointed by Obama as the director of Health IT, in the Office of the National Coordinator for Health IT. I sent him a congratulatory email, just an honest email just congratulating him and introducing myself, and he responded, actually, and we got to talking and he invited me for a day to look at what he does. Then it turned into a job, or summer job at least, and then that summer job led to a year-long job. So a lot of it, of course, is luck, but I think if you truly talk to the people that interest you, and keep in touch with them, and work hard and don't say no to opportunities that may be out of your comfort zone. I think that I've certainly said yes to things that I wasn't quite ready for, but then went there and ramped up quickly and found that you learn on the job in a lot of cases.
GAGLANI: Definitely. That's one way we got together, and it's funny that David Blumenthal connection I forgot to even make. We had him on the podcast in December. Now, he's president of the Commonwealth Foundation.
DR. HOAGLIN: Oh, right. Wow. Small world.
GAGLANI: Rishi, my co-host, who you know well, interviewed him. But yes, I love that, the cold email. When you operate in good faith and authentically, things just kind of compound and add up, and who knows what paths it'll take you down. Very interesting paths and very deep friendships can be developed.
The other question is, what is one final word you'd love our audience to know about you, about anything happening with COVID, healthcare in general, anything else you'd like to be able to share with our audience.
DR. HOAGLIN: Oh, wow. Let's see. I guess to kind of get into probiotics a little bit. If I had to say one thing, I would say "eat more fiber." Americans don't eat enough fiber. Our standard American diet is just not rife with fiber, for whatever reason. We need 25 to 30 grams a day. It is a good amount, but if you eat the right number of fruits and vegetables, it's not that hard to do. The reason is not just to have regular bowel movements, it's really to allow your gut microbiome to ferment that fiber into what's called short-chain fatty acids, or basically these fat globules that can travel to the gut wall to heal it, and can travel to the liver to make your body more insulin sensitive. Really, it makes it a lot easier for your body to work overall. So, add more fiber to your diet is probably the best advice I can give a general audience, as informational advice. That's what was going to keep your gut microbiome healthier, even more healthy than probiotics.
GAGLANI: I like that a lot. I mean, obviously one of the reasons we became friends early on, was your interest in being able to educate in health education. Very early on, you were helping me with Osmosis and thinking through that, and taking complex and sometimes hard-to-talk-about topics, like talking about bowel movements and turning them into engaging, interesting things. Especially because you've done both print and also TV journalism, when you were working for The Dr. Oz Show, so, taking these hour-long lectures, turning them into six-minute videos, turning them into 15-second sound bites, even.
DR. HOAGLIN: To be honest, the shows that had the highest ratings with Dr. Oz are the ones that talk about poop and mucus.
GAGLANI: Good to know, that never goes out of fashion. Still top of mind for most people, it seems.
DR. HOAGLIN: That's right.
GAGLANI: Mike, again, sorry to take you over but I really appreciate you taking the time.
DR. HOAGLIN: It was a lot of fun, Shiv. Thanks so much, always a blast with you and I really want to thank you again for having me.
GAGLANI: Of course, and thank you for the work you do to raise the line and improve healthcare capacity in so many different capacities. With that, I'd like to thank our audience for checking out today's show. Remember to do your part to flatten the curve and raise line. We're all in this together. Take care.