A Second Opinion with Victor Dzau, MD | A Second Opinion Podcast

A Second Opinion with Victor Dzau, MD

Dr. Victor Dzau is the president of the National Academy of Medicine, the independent, congressionally chartered organization originally created to advise the federal government and advance the wellbeing of the US population. Today, the National Academy’s mandate is much broader. It includes members from across the globe and partners with organizations worldwide to address the challenges that affect us all. Dr. Dzau is past president and CEO of Due University Health System, former chairman of medicine at Brigham and Women’s Hospital, and past chairman of the Department of Medicine at Stanford University. Today we discuss clinician burnout, the opioid epidemic, and the Academy’s landmark report on medical errors.

Dr. Victor Dzau:            Physicians have two times the suicide rate.

Bill Frist:                       Wow.

Dr. Victor Dzau:            And the recent surveys show 40 to 50% of them have some symptom of burnout. Nurses, same way. And in fact, ICU nurses have PTSD as well as many other health providers. It’s becoming a significant problem.

Bill Frist:                       You’re listening to A Second Opinion, your trusted source in gaging at the intersection of policy, medicine, and innovation, and rethinking American health. Dr. Victor Dzau is the president of the National Academy of Medicine, the independent, congressionally chartered organization originally created to advise the federal government and advance the wellbeing of the US population.

Bill Frist:                       Today, the National Academy’s mandate is much broader. It includes members from across the globe and partners with organizations worldwide to address the challenges that affect us all. Dr. Dzau is past president and CEO of Due University Health System, former chairman of medicine at Brigham and Women’s Hospital, and past chairman of the Department of Medicine at Stanford University. Today we discuss clinician burnout, the opioid epidemic, and the Academy’s landmark report on medical errors. I’m your host, Senator Bill Frist. Welcome to A Second Opinion.

Bill Frist:                       Dr. Dzau, the suicide rate among physicians is two times what it is the average population. Nurses have a similar sort of a burnout from work that has a huge emotional impact. Safety issues are involved for doctors and nurses as a product of this work environment, which has become so oppressive. I know you’ve done a lot of work on it, but let’s talk a little bit about-

Dr. Victor Dzau:            Sure.

Bill Frist:                       The physician burnout.

Dr. Victor Dzau:            Right.

Bill Frist:                       Tell me your perspective, just start out-

Dr. Victor Dzau:            Yeah.

Bill Frist:                       In what you’re doing-

Dr. Victor Dzau:            Yeah.

Bill Frist:                       Through the National Academy.

Dr. Victor Dzau:            Well, as you said, this is a big issues. Physicians have two times the suicide rate.

Bill Frist:                       Yeah.

Dr. Victor Dzau:            And the recent surveys show 40 to 50% of them have some symptom of burnout.

Bill Frist:                       Yeah.

Dr. Victor Dzau:            Nurses, same way. And in fact, ICU nurses have PTSD.

Bill Frist:                       Yeah.

Dr. Victor Dzau:            As well as many other health providers. It’s becoming a significant problem. I picture it this way, if you’re thinking about the people who are care providers, and they’re wellbeing is, shall we say, poor-

Bill Frist:                       Yeah.

Dr. Victor Dzau:            You’d be worried about the quality of patient care.

Bill Frist:                       Yeah, yeah.

Dr. Victor Dzau:            And there’s a good amount of data to show that quality of care, safety issues, absenteeism, and many others, right? So this is a very significant problem. The analogy I have is that if you go into a 737 and the pilot says, “You know, I feel burnout,” how would you feel?

Bill Frist:                       That’s right.

Dr. Victor Dzau:            Yeah.

Bill Frist:                       That makes it dramatic, you’re exactly right.

Dr. Victor Dzau:            Oh, yes. Yes, yes, yes.

Bill Frist:                       That is the same thing.

Dr. Victor Dzau:            So we are about caring for patients, and the biggest concern when we put patient in the middle and the providers around them, is the providers are not doing well, patient care is going to suffer. There are many other data that people should pay attention to aside from the issue of patient safety and quality, which is the impact on the health system itself.

Bill Frist:                       Mm-hmm (affirmative), right.

Dr. Victor Dzau:            There’s a study in nano internal medicine that shows that the impact and cost is about 4.6 billion dollars. Because you imagine that you have turnovers, you have to replace turnovers, you have errors, and you have many others. So this is a very big problem.

Bill Frist:                       The manifestation, it comes back to safety, to wellbeing, to suicide. If you go back to the root causes of it, and help me put it in perspective over time.

Dr. Victor Dzau:            Sure.

Bill Frist:                       Are things today worse than 20 years ago or 40 years ago? And then what are the root causes that ultimately result in these manifestations-

Dr. Victor Dzau:            Right.

Bill Frist:                       In this whole world of burnout-

Dr. Victor Dzau:            Right, right.

Bill Frist:                       Which has all the huge implications, but the root cause, what is it?

Dr. Victor Dzau:            Yeah, I think that we live in a much more complex world than 20, 30, 40 years ago. So maybe when I was in training, right?

Bill Frist:                       Yep.

Dr. Victor Dzau:            And of course when you look at the issues, and we’ve done that study at National Academy, looking exactly at what are the issues? They’re multifactorial. At the end of the day, we say it’s a system failure, where just like patient safety, it’s many issues which creates a system and you need to fix all of them, therefore improving the system. So what are they? Workload, right? Excessive administrative work, electronic health record, less time with the patient, that sense of satisfaction.

Bill Frist:                       Yeah.

Dr. Victor Dzau:            A culture, environment now of … kind of more business oriented, less compassionate care. The expectation of being competitive, being good at what you do and not recognizing your weaknesses. And it goes on and on, it’s really multifactorial.

Bill Frist:                       Is there something that can be changed that is easy? Is there low hanging fruit? You mentioned a series of five or six of the causes. Administrative work-

Dr. Victor Dzau:            Yeah.

Bill Frist:                       I mean, obviously physicians, like in an emergency room, many places are spending an hour taking care of patients and then an hour doing paperwork, administrative work.

Dr. Victor Dzau:            Yeah.

Bill Frist:                       Whether it’s them or they have to hire other ancillary personnel to do it, it’s still their work. So how do we address something as fundamental as that?

Dr. Victor Dzau:            Yeah. So I would say you have to fix the issue in the system, and there may be low hanging fruit, but it won’t get to the root cause, as you said.

Bill Frist:                       Yeah.

Dr. Victor Dzau:            Right? So fundamentally you have to adjust it. So we introduced a study in October.

Bill Frist:                       Yeah.

Dr. Victor Dzau:            This past year, and said if you look at the whole issue, it’s a system failure. Remember the days when we wrote the error as human?

Bill Frist:                       Yeah.

Dr. Victor Dzau:            Followed by quality chasm.

Bill Frist:                       Yes.

Dr. Victor Dzau:            And the issue is not blaming the individual doctors.

Bill Frist:                       Yeah.

Dr. Victor Dzau:            It’s not a personal weakness, it’s the failure of the system to support the providers so they can have wellbeing.

Bill Frist:                       Yeah.

Dr. Victor Dzau:            Right? So when you look at system, it’s about the culture, it’s about the workplace, it’s about the learning experience, it’s about support of each other, and importantly to create efficiencies whereby people don’t have to do that much administrative work. And electronic health record [inaudible] is one of the major causes because doctors are spending more time in front of the computer screen entering information than talking to their patients. We need to find a way to get rid of this. And I’ll tell you a little bit about our collaborative and later on-

Bill Frist:                       Yeah.

Dr. Victor Dzau:            How we try and solve this problem together.

Bill Frist:                       Yeah, would love to hear that, and the electronic health record is interesting, because we all know how important it is, especially in this world of a lot of data and big data. And that that can be mined in a way that could be very beneficial to patients. Is it the fact that technology hasn’t kept up? We’ve got the data, we’ve got this accumulation of data which we know is important. The demands are to digitize records, and to get the records-

Dr. Victor Dzau:            Mm-hmm (affirmative), yes, yes, yeah.

Bill Frist:                       Into a uniform format it can be used. But the technology, whether it’s voice recognition, or the way data’s actually entered where a lot of it’s by keyboard now-

Dr. Victor Dzau:            Right, right.

Bill Frist:                       Is it a matter of the technology and if the technology catches up that that will go away?

Dr. Victor Dzau:            I think it’s that, but I think more importantly it’s the time that’s taken, conditions, to work with the technology-

Bill Frist:                       Yeah.

Dr. Victor Dzau:            And taking them away from patient care. So for example, I think there’s a study that looked at how much a primary care physician spend with their patients versus spending with electronic health record. In an encounter of 15 minutes, 10 minutes are with the computer and five minutes with the patient.

Bill Frist:                       Yeah.

Dr. Victor Dzau:            Right?

Bill Frist:                       Yeah.

Dr. Victor Dzau:            So there’s a fundamental problem there, and I think the question should be, yes, you’re right, we need to collect information. Who should collect the information?

Bill Frist:                       Yeah.

Dr. Victor Dzau:            And what information should we collect?

Bill Frist:                       Right.

Dr. Victor Dzau:            So some of the criticisms of electronic health record are that they were meant more for administration, claims report, information like this, than for the patient care directly.

Bill Frist:                       Yeah.

Dr. Victor Dzau:            And should doctors be spending time entering that information-

Bill Frist:                       Yeah.

Dr. Victor Dzau:            Versus, in fact, spending more time with the patients?

Bill Frist:                       Right.

Dr. Victor Dzau:            So you asked me for a quick fix.

Bill Frist:                       Yeah.

Dr. Victor Dzau:            I think aside from the longer term fix which is we need to change the vendors, and to make sure they understand the customer are the clinicians.

Bill Frist:                       Right.

Dr. Victor Dzau:            And that the things you want them to do are related to patient care.

Bill Frist:                       Right.

Dr. Victor Dzau:            And that administrative work can be done by somebody else-

Bill Frist:                       Yeah.

Dr. Victor Dzau:            I think a quick fix, in my opinion, is the CEOs of these health systems should think about helping people to get scribes and workers to enter that record without asking doctors to do that.

Bill Frist:                       Yeah, yeah. Where the doctor’s just not looking down typing with the patient right before them.

Dr. Victor Dzau:            Yes, exactly, yeah.

Bill Frist:                       Losing that connection-

Dr. Victor Dzau:            Yeah.

Bill Frist:                       That empathy and the ability to connect.

Dr. Victor Dzau:            Exactly.

Bill Frist:                       When they’re sitting down looking-

Dr. Victor Dzau:            Yeah.

Bill Frist:                       Yeah, yeah.

Dr. Victor Dzau:            And their complaint is some of the data we’re asked to enter before we can complete our work on the screen-

Bill Frist:                       Yeah.

Dr. Victor Dzau:            Are not related directly to the patients.

Bill Frist:                       Yeah.

Dr. Victor Dzau:            Right?

Bill Frist:                       Yeah. And that’s sort of a call I think to physicians to get also more involved in the process.

Dr. Victor Dzau:            Absolutely.

Bill Frist:                       They’re the ones that are being … are suffering from this process, which has gone awry, but it means that they need to actually get in the field, and participate-

Dr. Victor Dzau:            Yeah.

Bill Frist:                       And to engage, and negotiate, and say, “No, have somebody else do the claims data, we need to be doing the clinical data, and this is the way the questions should be.”

Dr. Victor Dzau:            Yeah, exactly. So think about this, the purchasers or electronic health record are the CEOs and the head of health system.

Bill Frist:                       Yeah.

Dr. Victor Dzau:            Because as you know it costs several hundred million dollars-

Bill Frist:                       Yeah.

Dr. Victor Dzau:            [inaudible] concern or whatever, right?

Bill Frist:                       Yeah.

Dr. Victor Dzau:            And when I was running Duke we would pay 600 million dollars to create their epic system.

Bill Frist:                       Yeah.

Dr. Victor Dzau:            So the purchasers are looking at how can it help the entire system? The doctors are frequently the users, right? And so I think that what we need to do is to, as you said, get physicians engaged to say, “This is useful. This should be done by somebody else.” Right? And this is what we’re trying to do at National Academies, we have a thing called the Action Collaborative. We bring together all the stakeholders and we invite the vendors of electronic health record and others, and to have a discussion to say, “Look, you realize that your product is not user friendly.”

Bill Frist:                       Now they all come to same room or you have to be-

Dr. Victor Dzau:            They do.

Bill Frist:                       In different rooms?

Dr. Victor Dzau:            No, no, no, they come same room. The real question is, so we’ve been trying to get our stakeholders together to say, “If you’re buying the electronic health record, you should tell vendors what you need.”

Bill Frist:                       Right.

Dr. Victor Dzau:            Right?

Bill Frist:                       Yep.

Dr. Victor Dzau:            Versus having vendors to create something they believe the systems need, and then suddenly you end up using their version of the system.

Bill Frist:                       Yeah.

Dr. Victor Dzau:            Right?

Bill Frist:                       And I love that. Let’s use that as a stepping off point. Our audience listening to us right now in our conversation is a varied audience, it’s policy makers, it’s people in Washington, people in Nashville, Tennessee and the state capitals. On the innovation side it’s entrepreneurs, it’s people trying to solve problems, whether it’s in health services or beyond in the health sector. And everybody’s interested in health and wellbeing in the general sense, who’s listening to us. And one of the reasons they come to this podcast is they’re looking for a trusted source where they can hear directly from people-

Dr. Victor Dzau:            Absolutely.

Bill Frist:                       Like you, and in this world with so much information flowing around, people are writing in and they’re talking and saying the usefulness of the podcast is the trusted source. And I say that because I appreciate you being here, number one, but number two, the trusted source in so much of health and healthcare today is the National Academy of Medicine. And I’d like to spend a few minutes and have you give me and our listeners just a primer on the National Academy, how you actually function today addressing these issues. A little bit on the history of the National Academy, and you might even go back to Harry Schumann, which has-

Dr. Victor Dzau:            Sure.

Bill Frist:                       Such a pivotal changing, of course. But the National Academy-

Dr. Victor Dzau:            Right.

Bill Frist:                       Tell us a little about it.

Dr. Victor Dzau:            Well first of all, thank you. This podcast is so important. All of us who are very much in the field recognize we need trusted voices. Right?

Bill Frist:                       Yeah, yeah.

Dr. Victor Dzau:            Is the National Academy self sufficient? No.

Bill Frist:                       Yeah.

Dr. Victor Dzau:            And many public people don’t even know who we are. But I think we play a very important role in the-

Bill Frist:                       Hugely important.

Dr. Victor Dzau:            World of healthcare and policy. But I think having a person like you who’s trusted, is credible, and then using your judgment to know who’s to be listened to-

Bill Frist:                       Yeah.

Dr. Victor Dzau:            And who’s likely to be credible sources-

Bill Frist:                       Yeah.

Dr. Victor Dzau:            Help us disseminate information so much more, right?

Bill Frist:                       Yeah.

Dr. Victor Dzau:            These days with a cacophony of voices, people don’t know who to go to.

Bill Frist:                       Yeah.

Dr. Victor Dzau:            Right? I mean, if you just simply go to Google and ask a question, you’re going to get lots of different people. So we’ve always said that if there is a trusted source, and I think there’s not only one but multiple, but podcasts like this are so important. Because you reach tens and thousands of people, and then you ask people like Tom [Friedan 00:13:43], Tony [Fulcher] and others-

Bill Frist:                       Yeah.

Dr. Victor Dzau:            Who you know who are trusted, scientifically based, that help us disseminate our message.

Bill Frist:                       Yeah.

Dr. Victor Dzau:            Right?

Bill Frist:                       Yeah.

Dr. Victor Dzau:            And certainly it’s my dream that your podcast become the place to go to for information-

Bill Frist:                       Yeah.

Dr. Victor Dzau:            Because then we know that we can work with you-

Bill Frist:                       Yeah.

Dr. Victor Dzau:            To get our message out.

Bill Frist:                       Yeah.

Dr. Victor Dzau:            Right?

Bill Frist:                       Yeah.

Dr. Victor Dzau:            So that’s what we do at National Academy, because we’re founded … the National Academies, the founding academies, National Academy of Sciences, that’s 1863, chartered by Congress, founded by Abraham Lincoln, a time of Civil War, they need trusted, credible, scientific voices to advise the nation.

Bill Frist:                       Yeah.

Dr. Victor Dzau:            Right? That’s our history. Fifty years ago, health became such an important issue with passage of Medicare, many others, it became very clear that science includes health. And so the Institute of Medicine was founded as part of the NAS to do this job.

Bill Frist:                       Right.

Dr. Victor Dzau:            And as you know, you being a prominent member-

Bill Frist:                       Yeah, yeah.

Dr. Victor Dzau:            And so on-

Bill Frist:                       Yeah.

Dr. Victor Dzau:            We’ve done a great job-

Bill Frist:                       Yeah.

Dr. Victor Dzau:            In advising the nation on whole aspects of health throughout the 50 years.

Bill Frist:                       Yeah.

Dr. Victor Dzau:            And five years ago we constituted and call ourselves National Academy of Medicine, along with National Academy of Sciences, National Academy of Engineering, and Medicine, so three Academies.

Bill Frist:                       Right. And the Academy, is it government, is it private sector, is it semi-autonomous?

Dr. Victor Dzau:            Yeah.

Bill Frist:                       Where is this at?

Dr. Victor Dzau:            It is a independent nonprofit chartered by the government.

Bill Frist:                       Yeah.

Dr. Victor Dzau:            Created specifically to advise the government. So the good news is for all 150 whatever, and 50 for us, you and you’re in Senate, and others know who we are-

Bill Frist:                       Right.

Dr. Victor Dzau:            And you trust us because we bring the best experts and scientific evidence to give Congress and executive branch and the agencies the best advice.

Bill Frist:                       I love it.

Dr. Victor Dzau:            Right.

Bill Frist:                       And is it funded by government?

Dr. Victor Dzau:            It’s funded by the work that we do.

Bill Frist:                       Right.

Dr. Victor Dzau:            So about 70% by the government, and 30% now by foundations like Rockefeller, Robert Wood Johnson Foundations.

Bill Frist:                       Right.

Dr. Victor Dzau:            And some philanthropy.

Bill Frist:                       Yeah.

Dr. Victor Dzau:            But the point is, we are attacking, addressing the critically important issues in healthcare, and that we look for different sources of funding. As you know, we frequently get a request from Congress to say, “Can you do a study to give us recommendation so that we know where we’re going to go with policy, bills, and laws?”

Bill Frist:                       Yeah.

Dr. Victor Dzau:            But we can also be looking such as the issue of genome editing, where a foundation says, “This has such great implication, we trust you, can you do analysis [crosstalk 00:16:43]”

Bill Frist:                       And I love that currency.

Dr. Victor Dzau:            Yeah.

Bill Frist:                       And there are a lot of foundations who do different things, but the National Academy of Medicine, and the other Academies, but National Academy really focuses on current issues that have real practical import in terms of direction.

Dr. Victor Dzau:            Yeah.

Bill Frist:                       And so when you look at helping already such an intimate … affecting all of us in so many ways, people really want to know what’s the latest, how can things be changed and improved.

Dr. Victor Dzau:            So-

Bill Frist:                       So just come back to what you do and then the how you do it, which I think is why people trust you so much. Tell me about that.

Dr. Victor Dzau:            Yeah. Well, let’s just one I come back to your point about what’s trusted.

Bill Frist:                       Yeah.

Dr. Victor Dzau:            We know that people who know us, particularly governments, policy making organizations, trust us. We have a long track record. Earlier I mentioned to err is human.

Bill Frist:                       Yeah, to err is human, so-

Dr. Victor Dzau:            Back 20 years ago.

Bill Frist:                       Yeah, but share a little bit about-

Dr. Victor Dzau:            Okay.

Bill Frist:                       To err is human, because it was such a pivotal report.

Dr. Victor Dzau:            Absolutely. Twenty years ago we released this report and it was earthshaking.

Bill Frist:                       Yeah.

Dr. Victor Dzau:            Because we said up to 98,000 people in the Unite States die in hospitals because of medical errors. Now, you’re a doctor, I’m a doctor, I’m a cardiologist, you’re a surgeon, right?

Bill Frist:                       Right.

Dr. Victor Dzau:            And we say at the Mass General, “Are you kidding?”

Bill Frist:                       Yeah.

Dr. Victor Dzau:            Nothing like that happens to me.

Bill Frist:                       Yeah.

Dr. Victor Dzau:            Right? Until we see the data.

Bill Frist:                       Yeah.

Dr. Victor Dzau:            And that was I’ll just say a wake up call.

Bill Frist:                       It was earthshaking at the time.

Dr. Victor Dzau:            Earthshaking.

Bill Frist:                       Yeah.

Dr. Victor Dzau:            Absolutely.

Bill Frist:                       Yeah.

Dr. Victor Dzau:            And when people eventually see the data and understand it, suddenly people say, “Wow, there’s something wrong. We shouldn’t be in a profession that’s killing people.”

Bill Frist:                       Yeah.

Dr. Victor Dzau:            We should be in the profession of saving people.

Bill Frist:                       Right.

Dr. Victor Dzau:            That initiated an entire movement of patient safety. Not only US, but globally. We were the first to mention this, and of course 20 years later you don’t go to a hospital without someone double checking your identity outside or surgery, right, all that stuff-

Bill Frist:                       Yeah.

Dr. Victor Dzau:            I think is the result of this very important study. I think that’s a good example of what we do.

Bill Frist:                       So let’s go to the how. So you came in and it was a report, and then it was publicized, but to get to that point, to be trusted, do you bring scientists in, does it take a week?

Dr. Victor Dzau:            Yeah.

Bill Frist:                       Does it take a year? How do you chose the scientists that you bring in? Where do you get the data?

Dr. Victor Dzau:            First of all, why that topic, right?

Bill Frist:                       Yeah.

Dr. Victor Dzau:            I think what we have, we look at the topic is we have lots of smart members, advisors, and we’re always out there making sure we understand where the trends are, where the issues are.

Bill Frist:                       Yeah.

Dr. Victor Dzau:            And this became an internal discussion to my knowledge of the counsel of [IOM 00:19:43].

Bill Frist:                       Yeah.

Victor J. Dzau, MD

Dr. Victor Dzau:            That says we’re worried about this. And my predecessor, Ken Shine, took this on and found some resource to get us started and then got funding.

Bill Frist:                       Yeah.

Dr. Victor Dzau:            So that’s point number one. So just like you and I work on vital directions a couple of years ago-

Bill Frist:                       Right.

Dr. Victor Dzau:            We identified the big issues that need to be addressed, and that allows the Academy to say, “Let’s tackle this issue, let’s now do a deep dive on what are the things we need to do to address this issue.”

Bill Frist:                       Yeah, yeah. And just for our viewers on that, and this comes back to the how too, which I want to come back to again. After that report, from the Vital Directions, you and I personally-

Dr. Victor Dzau:            Yes.

Bill Frist:                       Went to the United States Congress and talked to the leadership-

Dr. Victor Dzau:            Exactly.

Bill Frist:                       Republican and Democrats.

Dr. Victor Dzau:            Yes.

Bill Frist:                       Because that’s who the National Academy serves, primarily, it serves the whole public. And had a conversation of this is what the smartest people-

Dr. Victor Dzau:            Yeah.

Bill Frist:                       Not even me, but the real smart people have found and have concluded-

Dr. Victor Dzau:            Yes, well-

Bill Frist:                       And that’s sort of the end of that.

Dr. Victor Dzau:            It was right at the time of the repeal discussion.

Bill Frist:                       Yeah.

Dr. Victor Dzau:            So we were adding information for them-

Bill Frist:                       Yeah.

Dr. Victor Dzau:            To consider for their decision.

Bill Frist:                       Yeah.

Dr. Victor Dzau:            Right? And we were always heading the right level, it’s about the patient, it’s about the value, it’s about innovation as well, those things. So whatever you decide, make sure we don’t lose those values.

Bill Frist:                       Yeah.

Dr. Victor Dzau:            Right?

Bill Frist:                       Yeah.

Dr. Victor Dzau:            Yeah.

Bill Frist:                       And it was literally you and me walking the halls, just like any other citizen-

Dr. Victor Dzau:            Exactly.

Bill Frist:                       But giving that information.

Dr. Victor Dzau:            So you already talked about some of the how’s, right?

Bill Frist:                       Yeah, so the hows-

Dr. Victor Dzau:            Yes, yeah.

Bill Frist:                       Again because the how to me is where the trust is generated. And but how do you pull these people together and how are they?

Dr. Victor Dzau:            Yeah. So first of all, once we find a topic, we usually consult a lot of people. Remember in the Vital Direction, we created a steering committee.

Bill Frist:                       Yep.

Dr. Victor Dzau:            Right, to say what’s important. So in a study like To Err Is Human, we had consulted a lot of people, planned for it, and then created a committee. This committee is going to take a deep dive in studying all of the literature, all the evidence, deliberate, debate, and eventually come with what we call evidence based recommendations to say what needs to be done.

Bill Frist:                       Mm-hmm (affirmative).

Dr. Victor Dzau:            Right? The process, a committee’s usually about 20 people. It can be anywhere from 16 to 24. That takes about a year. And sometimes over a year because we want to be careful and deliberate.

Bill Frist:                       Yeah.

Dr. Victor Dzau:            Importantly, we follow both the Federal Advisory Commission Act, as well as we also exempt it. What I mean is we have public hearings, so the public can come in and say their feeling about what we’re doing. We express that we will present publicly, and then the committee will listen to this, but we exempt in the sense that we can private deliberations.

Bill Frist:                       Yeah.

Dr. Victor Dzau:            So this way you can really debate this cause. But our condition is that people have to have consensus to come out with the recommendations so that we can say we can take it to the bank.

Bill Frist:                       Yeah.

Dr. Victor Dzau:            This is our recommendation to Congress.

Bill Frist:                       Yeah.

Dr. Victor Dzau:            And to the public.

Bill Frist:                       That’s asking a lot, consensus among-

Dr. Victor Dzau:            Oh, it’s a huge amount.

Bill Frist:                       Twenty people.

Dr. Victor Dzau:            Well, sometimes we do have people who say, “I just can’t sign off,” so they’re the minority opinion-

Bill Frist:                       Sure, yeah.

Dr. Victor Dzau:            But most of them … we did one on drug pricing.

Bill Frist:                       Yeah.

Dr. Victor Dzau:            You can imagine how complicated that is.

Bill Frist:                       Yeah.

Dr. Victor Dzau:            Right?

Bill Frist:                       Yeah.

Dr. Victor Dzau:            And we had … but we said, “Look, we need to have pharma, biotech, the [inaudible] industry at the table.

Bill Frist:                       Yeah.

Dr. Victor Dzau:            And people say, “Well, they’re conflicted.” But how can you talk about that without them being at the table, right? So we do create the right committee so that they’re well represented, but as much free of conflict as we possibly can-

Bill Frist:                       Yeah.

Dr. Victor Dzau:            And do the deep dive work.

Bill Frist:                       Yeah.

Dr. Victor Dzau:            Now that’s not done yet. So when they finish this study, it goes to review. We have a report review committee that has … throughout the study there’s a monitoring and coordinator that monitors … well, one of the members, usually, that guides the study so that when it goes to review, it’s like a journal review except we usually get about 12 or more reviewers-

Bill Frist:                       Yeah.

Dr. Victor Dzau:            And you have to satisfy reviewers, too.

Bill Frist:                       Yeah.

Dr. Victor Dzau:            That’s another process. So all told, a year to a year and a half. We’re trying to now streamline this, because it takes a little too long for policy makers.

Bill Frist:                       Yeah.

Dr. Victor Dzau:            Right?

Bill Frist:                       Yeah.

Dr. Victor Dzau:            So-

Bill Frist:                       If they’re asking a question, that means they need the answer quickly.

Dr. Victor Dzau:            Exactly, exactly.

Bill Frist:                       And two and a half years is a long time.

Dr. Victor Dzau:            Yeah, so we are doing a lot of-

Bill Frist:                       Yeah.

Dr. Victor Dzau:            Internal look at how to be more innovative, how to be more efficient. But I think the main I would say emphasis of what we’re talking about is a thoroughness and thoughtfulness of such a report. And there, people trust it.

Bill Frist:                       Yeah.

Dr. Victor Dzau:            Right?

Bill Frist:                       Yeah. I think that’s exactly right, and I think in this day and time where what most people who are listening us today think of Washington DC, where the Academy is, and the Congress, everything is so divided. It’s liberal versus conservative and there’s nothing in between going on, and it’s Republican versus Democrat, there’s nothing in between going on. In truth, if you look in the aggregate, especially manifested by the National Academy, you’re bringing in a collaborative way everybody to the table.

Dr. Victor Dzau:            Yes.

Bill Frist:                       All of the important stakeholders, the players that are there, the smartest people, the people who have sort of written the papers and studied, as well as representatives from the American people-

Dr. Victor Dzau:            Yeah.

Bill Frist:                       That everybody’s at the table.

Dr. Victor Dzau:            Absolutely. We take pride that we call ourselves neutral.

Bill Frist:                       Yeah.

Dr. Victor Dzau:            We don’t take any political positions.

Bill Frist:                       Yeah, yeah.

Dr. Victor Dzau:            And what we do is we want facts, etc.

Bill Frist:                       Yeah.

Dr. Victor Dzau:            And one of the issues these days in such a polarizing environment, how do the Academy do its work, we would not tackle any political issues.

Bill Frist:                       Yeah.

Dr. Victor Dzau:            We only tackle issues which are based on evidence in order to make policy correctly by the government or others.

Bill Frist:                       Yeah, yeah. But then politicize it if they [crosstalk 00:25:51]-

Dr. Victor Dzau:            Yeah, right.

Bill Frist:                       Is the … and then so just the last phase, and you’ve got the report, it is there, you report it out, I mentioned a little bit that you and I personally had engaged in that-

Dr. Victor Dzau:            Yeah.

Bill Frist:                       As we go through. But then what happens to it after that? So many reports by so many think tanks-

Dr. Victor Dzau:            Yeah.

Bill Frist:                       They’re very good, and they sit on a shelf, and then there’s another report. People come in-

Dr. Victor Dzau:            Yeah.

Bill Frist:                       And the follow through is what-

Dr. Victor Dzau:            Is so important.

Bill Frist:                       You mentioned To Err Is Human-

Dr. Victor Dzau:            Yeah.

Bill Frist:                       That for 15 years-

Dr. Victor Dzau:            Yes.

Bill Frist:                       That affected not just the-

Dr. Victor Dzau:            Yes.

Bill Frist:                       United States, but globally.

Dr. Victor Dzau:            Right.

Bill Frist:                       What happens in all 6,000 hospitals-

Dr. Victor Dzau:            Right, right.

Bill Frist:                       In America.

Dr. Victor Dzau:            Right.

Bill Frist:                       That sort of impact. But procedurally, is there anything that’s done in a standard report-

Dr. Victor Dzau:            Sure.

Bill Frist:                       In terms of release?

Dr. Victor Dzau:            Yes. Well first of all, aside from releasing the report and holding what’s equivalent of a press conference to have reporters that are to cover this, before we even do that we usually go up to the Hill and meet with Congress,

Bill Frist:                       Right.

Dr. Victor Dzau:            Staff.

Bill Frist:                       Yeah.

Dr. Victor Dzau:            To let them know about the report the day before.

Bill Frist:                       Yeah.

Dr. Victor Dzau:            And to get them well prepared for some of the recommendations.

Bill Frist:                       Yeah.

Dr. Victor Dzau:            So there’s a lot of engagement in this case with Congress, if the report is relevant to Congress. But maybe more importantly is what we do following this. So To Err Is Human, we have 12 different studies that followed the initial studies.

Bill Frist:                       Wow.

Dr. Victor Dzau:            That tackles, okay, if you look at this whole medical error area and it’s a system failure, how do you address the workforce? How do you address the use of digital technology? How do you look at the cancer area, and so on, so on. So it’s not just one off, it’s a series that continues to provide advice on what to do and how to tackle this.

Dr. Victor Dzau:            Second thing we’re doing of course is we have the whole communication shop, and we become even more aware these days that we need to, like you and I did, disseminate the report, talk to stakeholders, and the staff, etc.

Bill Frist:                       Yeah, yeah.

Dr. Victor Dzau:            Third is that we’re now causing social media and many other media to continue dissemination. But the most interesting one I want to tell you about is what we call Action Collaborative. I want to give you two examples.

Bill Frist:                       Yeah.

Dr. Victor Dzau:            So on, on the opioid, which we’re going to talk about-

Bill Frist:                       Yeah.

Dr. Victor Dzau:            Possibly.

Bill Frist:                       Yeah.

Dr. Victor Dzau:            We did a study to look at exactly what you said, what are the causes, what do you need to do, what do you recommend to do, right?

Bill Frist:                       Yeah.

Dr. Victor Dzau:            But what we then to is to say if these recommendations need to be enacted upon, who are the stakeholders who should be doing this?

Bill Frist:                       Yeah.

Dr. Victor Dzau:            So then we convene the stakeholders, and do a public, private partnership. And then let the stakeholders say, “Well we’re going to work together to solve this problem together-”

Bill Frist:                       Yeah.

Dr. Victor Dzau:            “Solve that problem together, etc.” So suddenly you have actions that-

Bill Frist:                       Action, yeah.

Dr. Victor Dzau:            Follow the report, right?

Bill Frist:                       Yeah, execution, yeah.

Dr. Victor Dzau:            So opioid is a great example.

Bill Frist:                       Yeah.

Dr. Victor Dzau:            One big gap is education, and Academy, we’re perfect for medical education, right?

Bill Frist:                       Yeah.

Dr. Victor Dzau:            What do medical schools teach our students about pain treatment, addiction, opioid use, and substance use disorder? What do residents learn about this? And when you’re in practice, how do you get continued medical education?

Bill Frist:                       Yeah.

Dr. Victor Dzau:            And I will say today is totally fragmented. So using our convening power, we get people together and say, “Let’s create an education continuum.”

Bill Frist:                       I love it, yeah.

Dr. Victor Dzau:            Not only for doctors, but for nurses, pharmacists, and dentists.

Bill Frist:                       Yeah.

Dr. Victor Dzau:            Right?

Bill Frist:                       Yeah.

Dr. Victor Dzau:            So we’re working in the midst of doing that and I’m going to talk about that later on today.

Bill Frist:                       Yeah, yeah.

Dr. Victor Dzau:            And so that’s a perfect example. Scott Gottlieb, the FDA commissioner, said to us, “Can you help us create the right prescription guideline?” Because if you go to dentist, you make it 14 days of Oxycontin.

Bill Frist:                       Yeah.

Dr. Victor Dzau:            Why?

Bill Frist:                       Yeah.

Dr. Victor Dzau:            You don’t need it, right?

Bill Frist:                       Yeah.

Dr. Victor Dzau:            But if you go to somebody else, [inaudible] other indications, so there’s not a good way of looking at what do you really need?

Bill Frist:                       Yeah.

Dr. Victor Dzau:            So we created a report with standard framework, evidence, to say 20 conditions when you apply this framework to say now doctors know what to do.

Bill Frist:                       Yeah.

Dr. Victor Dzau:            We’re bringing … accrediting and licensing bodies to be part of this.

Bill Frist:                       Yeah.

Dr. Victor Dzau:            So now we begin to create the system.

Bill Frist:                       And nobody else could really do that. I mean, that’s the unique thing. It’s sort of obvious, like say Tennessee, unfortunately we were the worst state in terms of number of prescriptions going out.

Dr. Victor Dzau:            Right.

Bill Frist:                       At a per physician or per patient level of opioid, it was just inexcusable, and all. So what does a policy maker do? Where do they look to say what is the appropriate number-

Dr. Victor Dzau:            Exactly.

Bill Frist:                       Coming in, there’s nowhere to go.

Dr. Victor Dzau:            Right.

Bill Frist:                       But to have you step in and do that has huge power.

Dr. Victor Dzau:            Exactly.

Bill Frist:                       And then the policy maker, if the bill fits there’s a policy maker who can say, “Listen, the most experts in the world say it’s three days after a dental procedure and not 14.”

Dr. Victor Dzau:            Yes.

Bill Frist:                       And so the power of that is just unbelievable.

Dr. Victor Dzau:            Right.

Bill Frist:                       Why don’t we close a little bit more on the opioid, because it’s another very recent one. And we are today at Lake Nona, the impact forum there, and you’ll be addressing the audience there today. Give me three minutes from your 30 minute discussion today. You have to say, we’ve got coronavirus, sort of a big concern now, but in terms of impact on the American people, it has touched every family listening to us-

Dr. Victor Dzau:            Oh, yes.

Bill Frist:                       Or their extended family, every family in America today.

Dr. Victor Dzau:            Yes.

Bill Frist:                       The causes are multifactorial, but tell me sort of … you can abbreviate it, but who came to you to say, “Okay, let’s look at opioids. This is the charge, this is what you need to do,” and then how you did it, using the model that your outlined.

Dr. Victor Dzau:            Yeah. So looking back on the burnout, the people who came to me were people who ran the double AMC, the medical school accrediting party, the ACGME, they had people running residency programs. And many physician that says, “We need a neutral body that can bring all of us together to act together.” And of course being a physician it was very easy to see why we should be doing this. On the opioid side, it’s actually coming from many different directions, I can’t talk about a single event.

Bill Frist:                       Yeah.

Dr. Victor Dzau:            But it’s very clear that it’s such a big problem, and we at National Academy should be doing something in this.

Bill Frist:                       Right.

Dr. Victor Dzau:            And it became fairly clear in a number of these planning meetings that coordination is a big problem.

Bill Frist:                       Yep.

Dr. Victor Dzau:            Right? Good effort. I would give a lot of credit to everybody putting resources and time, but this is well coordinated.

Bill Frist:                       Yeah, yeah. Yeah.

Dr. Victor Dzau:            So collective action is very important. So as the Surgeon General said, attacking the opioid crisis is like eating an elephant, you can’t do it alone, you have to have a whole bunch of people eating pieces of it.

Bill Frist:                       Yeah, yeah, yeah.

Dr. Victor Dzau:            So what we decided to do is a public, private partnership, call it collaborative.

Bill Frist:                       Yeah.

Dr. Victor Dzau:            So the assistant secretary of health, Admiral Brett Giroir, who’s in charge of opioid for HHS, is co-chairing this with me, along with Jonathan [Pullen 00:33:11]-

Bill Frist:                       Yeah.

Dr. Victor Dzau:            From [XCA 00:33:12].

Bill Frist:                       Yeah.

Dr. Victor Dzau:            So we have a private sector-

Bill Frist:                       Yeah.

Dr. Victor Dzau:            Point of view, a public sector point of view, a nonprofit, and then Ruth Katz from Aspen Institute, so all of us are co-chairs.

Bill Frist:                       I love it, yeah.

Dr. Victor Dzau:            We get to 60 different organizations representing the interested party in this issue-

Bill Frist:                       Yeah.

Dr. Victor Dzau:            From of course dentists, physicians, to NIH, CDC, SAMHSA, you name it, to CVS-

Bill Frist:                       Yeah.

Dr. Victor Dzau:            Pharmacy, to dentists.

Bill Frist:                       Yeah.

Dr. Victor Dzau:            So this group start working together say, “How do we solve this problem together?”

Bill Frist:                       Yeah.

Dr. Victor Dzau:            As I indicated, one area became very clear is help profession education. Because as you know, part of the problem, we have to own up to it, is that our health professions, doctors, are writing too many prescriptions.

Bill Frist:                       Yeah.

Dr. Victor Dzau:            Right?

Bill Frist:                       Yeah, yeah.

Dr. Victor Dzau:            And so that’s one area. We’re working hard on this. We believe that when you’re done with this, there will be such clarity that people will know what to teach, when to teach, etc.

Bill Frist:                       Yeah.

Dr. Victor Dzau:            Right?

Bill Frist:                       Yeah, yeah.

Dr. Victor Dzau:            Second is prescription I mentioned.

Bill Frist:                       Yeah.

Dr. Victor Dzau:            How to get clarity in prescription so people know how to use it. Third is looking at prevention, treatment, and recovery.

Bill Frist:                       Yeah.

Dr. Victor Dzau:            Again, 20% of people with substance use disorder have access to treatment facilities. And we also know that if you use the methadone, [inaudible] morphine and others, it works.

Bill Frist:                       Right.

Dr. Victor Dzau:            So our recent report says you’ve got to prescribe it, and not hold back and wait for all the other things in place.

Bill Frist:                       Yeah.

Dr. Victor Dzau:            And of course the research education, so we’re working on this collectively. So as you asked me before-

Bill Frist:                       Yeah.

Dr. Victor Dzau:            From a good idea, from reports, we’re getting people to work together under our roof.

Bill Frist:                       Yeah.

Dr. Victor Dzau:            We’re convening, we’re giving the support.

Bill Frist:                       Yeah.

Dr. Victor Dzau:            And people are collectively solving problems together.

Bill Frist:                       Well what I love about is a collaborative, in the sense that everybody comes and contributes, but it’s also, at the Academy, a safe environment.

Dr. Victor Dzau:            Yes.

Bill Frist:                       Where when people come in, yes, they represent their past, but they don’t have to be fighting in some way protecting turf, that they can be trusted by the other people, sort of a culture of understanding.

Dr. Victor Dzau:            Absolutely true.

Bill Frist:                       And on the opioid, is it-

Dr. Victor Dzau:            And what’s wonderful-

Bill Frist:                       Yeah.

Dr. Victor Dzau:            About this is that many government leaders participate in this.

Bill Frist:                       Yeah.

Dr. Victor Dzau:            So at by beginner’s leadership consortium, we have FDA, CDC, CMS all at the table with the CEOs and academics-

Bill Frist:                       Yeah.

Dr. Victor Dzau:            To discuss about healthcare.

Bill Frist:                       Yeah.

Dr. Victor Dzau:            In the opioid, we have NIDA, SAMHSA, CDC at the table.

Bill Frist:                       Yeah.

Dr. Victor Dzau:            Along with the other sectors to talk about how to solve the problem together.

Bill Frist:                       That’s sort of bringing everybody to the table just-

Dr. Victor Dzau:            Yeah.

Bill Frist:                       To go on as much as people would like in other areas, which is the unique role of the National Academy. Just finishing up on the opioid, was there a final report or is it an ongoing …

Dr. Victor Dzau:            We have several reports.

Bill Frist:                       Yeah.

Dr. Victor Dzau:            But it’s still ongoing.

Bill Frist:                       Yeah.

Dr. Victor Dzau:            So several reports including prescription-

Bill Frist:                       Yeah.

Dr. Victor Dzau:            Treatment.

Bill Frist:                       Yeah.

Dr. Victor Dzau:            And looking at infectious disease because they’re [inaudible] the injection at the same time HIV. Many other issues-

Bill Frist:                       Yeah.

Dr. Victor Dzau:            We looked at. But, we’re on a continuous journey. What we’re now looking at is the idea of systems leadership.

Bill Frist:                       Yeah.

Dr. Victor Dzau:            That is looking at where we’re taking this initiative, [inaudible] and connecting with all the other activities around this-

Bill Frist:                       Right.

Dr. Victor Dzau:            So that we can see a collective impact.

Bill Frist:                       Yeah. I know we need to bring things to a close, and what I’d really like to do is sometime spend an hour just on you, because you’re an amazing individual-

Dr. Victor Dzau:            Oh, thank you, yeah.

Bill Frist:                       And you and I have crossed clinically in the past, you’ve run one of the largest health systems at Duke, you’re now at the National Academy itself. But my final question is that you are a doctor. And all of it comes back at least to a beginning of very active in research, active in clinical care, active with as a practicing sort of physician. What role has that played when you go to run a large health system? Which is a lot of business as well as medical care, or the National Academy, where you really are at the peak of the most trusted institution in health and wellbeing in America today. But coming back to those early days, how has that impacted?

Dr. Victor Dzau:            You know, I’m looking at you with great admiration, I think what you’ve done is amazing. As a physician, surgeon, and a great thinker, but also working in Congress, a leader of Senate. You’ve done a lot more than I have.

Bill Frist:                       You’re very nice-

Dr. Victor Dzau:            Truthfully.

Bill Frist:                       I’m a good enough politician, I’m not going to let you switch it, but you’re very nice.

Dr. Victor Dzau:            Okay.

Bill Frist:                       But come back, so about the-

Dr. Victor Dzau:            Don’t you think it’s a collective experience, right? I mean, I was born in China and I’m a true immigrant-

Bill Frist:                       Yeah.

Dr. Victor Dzau:            To this country. I came when I was 18 to go to university on my own, and then of course I got taken by the bug of medicine. But my experience as refugees from China after the second World War had great impact on me in terms of poverty, disease. My grandparents died of tuberculosis. So then, of course I ran into people like Jim [inaudible] and others which got my the academic medicine bug. So I’ve been able to kind of, shall we say, take many of my life’s experience in ways together.

Bill Frist:                       Yeah.

Dr. Victor Dzau:            At one point, and I still do research, I was quite a good researcher.

Bill Frist:                       I know it.

Dr. Victor Dzau:            Then I became the [inaudible] chief of cardiology at Stanford.

Bill Frist:                       Yeah.

Dr. Victor Dzau:            Chair of Medicine at the Brigham Harvard. And then at Duke. So it was following the academic pathway, but bringing the many experiences you have in your life. So to me that’s why this job was so satisfying.

Bill Frist:                       Yeah.

Dr. Victor Dzau:            Because along the way I’ve worked with Paul Farmer, Jim Kim in global health. I created the Global Health Institute at Duke. Along the way I became very active in community within Durham, of how to practice like you are.

Bill Frist:                       Yeah.

Dr. Victor Dzau:            The way you are.

Bill Frist:                       Yeah.

Dr. Victor Dzau:            And really care about these issues. So for me it’s really the totality of what we’re all about.

Bill Frist:                       Yeah.

Dr. Victor Dzau:            And this kind of job, I think to me is I would say my way of giving back-

Bill Frist:                       Yeah.

Dr. Victor Dzau:            To this nation.

Bill Frist:                       Yeah.

Dr. Victor Dzau:            But being able to look at how can we make a difference in so many challenges that we face. And of course I’m so lucky to have people like yourself and others, and given a great platform to look at can we make a difference in this area of burnout-

Bill Frist:                       Yeah.

Dr. Victor Dzau:            Or the opioid, or in mental health, or in other areas.

Bill Frist:                       Yeah. It’s a remarkable ongoing story, and from your days of taking care of patients and then doing the research, which is … I’ll share it on our website, the vast research you’ve done in cardiovascular disease, and then in the health systems and introducing global health, because 30 years ago global health was not the center of focus of every university, every academic center in America-

Dr. Victor Dzau:            That’s right, yeah.

Bill Frist:                       But you really led on that, and-

Dr. Victor Dzau:            Mm-hmm (affirmative), yeah.

Bill Frist:                       The HIV/AIDS and the infectious disease work around the world, we see coronavirus today, but a lot of its built on your interest globally with people like Paul Farmer who-

Dr. Victor Dzau:            Mm-hmm (affirmative), yeah.

Bill Frist:                       Who were in the field itself. And then at the National Academy, but all of it comes back to sort of the increasing scale to the gifts and opportunities you were given. And I like the sort of giving back-

Dr. Victor Dzau:            Yeah.

Bill Frist:                       Because everybody listening to us, everybody watching us now has been affected by your life. That’s pretty good. And that’s pretty amazing. Everybody listening to this.

Dr. Victor Dzau:            Wow.

Bill Frist:                       And I say that and our listeners say, “Well, you’re overstating, that’s not true.” And I know you [crosstalk]

Dr. Victor Dzau:            I think we all did it together.

Bill Frist:                       Yeah, well, I know. You’re very humble. But thank you so much for-

Dr. Victor Dzau:            Oh, thank you.

Bill Frist:                       Being with us today, and look forward to a continued conversation-

Dr. Victor Dzau:            It was a lot of fun, yeah.

Bill Frist:                       We both have a lot to do in the field that you’re working in and leading.

Dr. Victor Dzau:            Thank you.

Bill Frist:                       Thank you so much.

Dr. Victor Dzau:            Thank you very much.

Bill Frist:                       Appreciate it, Victor.

Dr. Victor Dzau:            Thank you.

Bill Frist:                       This episode of A Second Opinion was produced by Todd [Schlesser 00:41:43], the Modus Creative Group, and Snapshot Interactive. You can subscribe to A Second Opinion on Apple Podcasts, Spotify, or wherever you are listening right now. You can also watch our interviews on YouTube and on our website. And be sure to rate and review A Second Opinion so we can continue to bring you great content. You can get more information about the show, its guests, and sponsors at ASecondOpinionPodcast.com. That’s ASecondOpinionPodcast.com.

Bill Frist:                       A Second Opinion broadcast from Nashville, Tennessee, the nation’s Silicon Valley of health services, where we engage at the intersection of policy, medicine, and innovation.