Scott Syphax: Dr. David Lubarsky was named vice chancellor of Human Health Sciences and chief executive officer of UC Davis Health in mid 2018. He joins me to talk about UC David Medical Center and the UC Davis Schools of Medicine and Nursing, next on Studio Sacramento. James Beckwith: At Five Star Bank, we create thoughtful solutions to help the capital region thrive, from economic development and education to public health and safety, issues that are vitally important to Sacramento’s prosperity. We’re proud to be part of the conversation and hope you’ll join in. Annc: This Studio Sacramento episode is supported by UC Davis Health where doctors, nurses and researchers share a passion for advancing health. Learn more about their latest medical innovations at health.ucdavis.edu. ♪♪ ♪♪ Scott: Dr. Lubarsky, with everything that you’ve done in your career and an amazing place that you were in in the south, why did you come and take this opportunity here in Sacramento? David Lubarsky: Well Scott, you know, UC Davis is an amazing organization. A lot of people really don’t appreciate its national stature and the amount of groundbreaking and nation leading research that’s going on here as well as the super high quality of its health care system. And the opportunity to lead an organization like that and work with all the great people who are already here on the ground in the state capital of the greatest state in the nation, it was just a great opportunity. Scott: Explain to us exactly what is UC Davis Health? Because when we think of UC Davis, we think of the entire university. Tell us about the part that you lead and what it does in this region. David: Sure. Well, just a couple quick facts about the health system. The health system is comprised of all the doctors who work there, there are about 1,000 physicians, all the basic science, research faculty in the School of Medicine, all of our students in the Nursing School and the Medical School. All of our patients, so we have about a million outpatient visits a year. And of course the thing that most people associate with UC Davis Health, which is our great hospital. A lot of people, it’s always ranked in the top 50 in the United States and we’re really getting very close to cracking the top 20 in the United States. Scott: Really? David: Yeah. It’s an amazing organization. All that put together, which is all on the Sacramento campus, that’s the organization. Scott: In Sacramento, we think of it as our region’s trauma center, right? David: And it is. Scott: And so we see the helicopters fly in and everything else, but what are the things that UC Davis is known for both nationally and internationally that sometimes we in Sacramento don’t appreciate? David: Well that’s a great question. I think that there’s so much that we do here. For instance, locally of course we’re the leaders in the world around valley fever which affects the Central Valley and investigates its causes and its potential cures. But things less esoteric and more perhaps known to the public, things like Alzheimer’s. We’re one of the top ranked Alzheimer’s research centers in the United States, one of only 10 Alzheimer’s disease centers funded by the federal government. And it’s something that has become a real scourge of parents, which is autism. Now one out of 64 children born probably a diagnosis somewhere on the spectrum of autism. Our Mind Institute formed many years ago has been the number one funded research organization in the United States looking after both diagnosis and cures for autism for years and most people don’t really appreciate how great a neurosciences group we have here. As a matter of fact, our neurosciences group is the number one nationally funded group in the United States. Scott: It’s the number one nationally funded group in the country? David: Yes. And UC Davis itself is currently 27th in national funding for research, you know, along the likes of Duke or Hopkins, Harvard, and so we just don’t publicize how great we are. We have a degree of humility here that doesn’t always serve us that well because people don’t really appreciate what a jewel is in their backyard. Scott: It’s a medical condition that affects a lot of the Sacramento region for lots of reasons. Maybe you can help work on that as well. As an anesthesiologist by training, what aspect of the work outside of your duties in running the entire system, what aspect of the medicine excites you most? David: Well you know, it’s funny. I was just at a symposium around cancer and normally when you think about cancer, you think about, “I have a tumor, I have to treat the tumor.” But our NCI designated cancer center, again, one of 68 in the United States of America as a top ranked cancer center, was really looking at why do we get tumors in the first place. And they’ve created an amazing breadth of investigation across multiple schools, agriculture, veterinary, environmental sciences as well as medicine to try and figure out what in our lifestyle, our environment, in our micro biome, the bacteria that lie in our gut, what about all the exposures we get in our environment lead us to get cancer? And only UC Davis, one of the broadest, as a university, its ability to bring colleagues together across a tremendous breadth of study is unmatched almost in the United States. So we’ve drawn from both the main campus and its research expertise and our own on the medical campus to start addressing how can we predict and prevent people from development cancer? And there’s a whole group of 40 researchers who came together this morning that I had the privilege to interact with. Scott: Another person from UC Davis who came on the show to talk about the work that’s been done in stem, and stem, and you mentioned the genome, those types of areas of inquiry always, you hear a lot about their promise. What’s the reality of what we as patients might expect is going to come out through the health care world in the next couple of years that will attack things like cancer and other conditions? David: You may have heard in the last two days there have been two announcements of patients cured of HIV with stem cells. Now, rare and it’s very complex, I won’t go into the details, it’s not going to be for everybody, but just the idea that we could somehow or other regenerate normal cells within our own body by programming it directly, it’s just an amazing opportunity. Again, UC Davis has one of the world leading stem cell institutes. Our Institute for Regenerative Cures. We have more than 100 ongoing studies. We have companies who are working on commercializing some of those initiatives and I believe that in, maybe not two years but in five years, I’m counting on them being able to rebuild the meniscus in my knee. I’ve had orthopedic surgeons, due to overtraining, take them out a couple of times and nothing would please me more than to see us actually be able to regenerate some of our own internal organs like that. And I think that that’s the promise, that medicine in the future is going to be, what I call, from the inside out and always on, meaning we’re going to give ourselves the capability to repair our own systems and to monitor our own systems and our doctors are going to be hooked up to us through the internet and they’ll let us know when we need to come see them. Scott: That’s an interesting evolution. Marc Andreessen, who was the inventor of Mosaic which led to the World Wide Web, years ago said that he was very interested in health care and what could be done to make health care more relevant in terms of not just curing diseases but elevating general health. And so he walked into his doctor’s office, so the story goes, with his medical records and his physician said, “Tell me what’s wrong,” and he said, “No, I want you to tell me how to get more right.” And so it almost sounds like what you’re talking about is not just curing conditions but also figuring out with all those other disciplines, how is it that we can optimize more stuff. David: Right, and I think that it is appropriate individualized feedback and advice that, really, much of what we do is by algorithm, meaning, you know, there’s a set of conditions like, “Oh, my blood sugar’s high, I need to do this,” or, “My blood sugar’s low and I need to do that.” Doctors don’t really need to intervene if we build that into the information and education system. And the way that you reach patients these days is through digital means, so figuring out a way that they’re always connected and always getting the advice they need in a timely fashion, that’s a way actually to cut down on costs and improve health. Scott: So with all of these things going on, not just internally within the institution and the Medical Center but in the broader health care environment, what’s the way forward? What’s your vision for where UC Davis Health System evolves to? David: Right. I’m going to talk a little bit about UC Davis itself but then in general about the health care economy. UC Davis itself I think is entering a new era in a new phase and one that everybody in the organization is embracing, which is that we have some unique capabilities and our goal should be to complete the other health systems around us, not compete with them. You know, we bring a thousand subspecialty physicians to the market and we need to be leveraging their advanced skillsets on behalf of patients everywhere. And so to do so, we need to think outside of the box of our hospital or our clinics and really start to broaden the support and advice that we can provide through telemedicine. And we are really working on partnerships across a broad range of opportunities in order to really start to do that. And our goal is to bring more care closer to patients’ homes and eventually into patients’ homes so that they can be conveniently served and only come down to the really big box hospital when they really have no other choice and really to make it more convenient to get better health care. Scott: That’s an interesting perspective because the way that the paradigm has always worked is that the big systems, UC Davis, Sutter, Dignity, KP, all competed for premium patients. Everyone had to do their share with regards to the underserved or government pay whether it’s on Medicare or Medicaid. But it was just a big competition. You’re describing what sounds like is something very different as a business model. David: It is, and because I firmly believe that we can provide care to very complex patients, still have a business model that’s totally sustainable and support our colleagues distant communities so they can provide better care there. Right now, I will tell you that our model is working. When I got here, our census was closer to 80 to 85%. Lately, the bed occupancy at noon is about 110 to 120% and by midnight it’s just below 100% every day. So the philosophy is working which is that if we are a support to all of our colleagues, they will support us by allowing us to take care of the patients who need us and that’s first and foremost. And second, northern California’s a big place and it’s growing and the population is growing, so there’s less need to compete as opposed to making sure that our health care that we offer in this region is the best in the world. Scott: How do you deal with the more needy parts of the population environment? What you’re talking about in terms of complexity of care, that affects everybody but historically UC Davis in particular has really been the place, the final place ultimately where the poor, the indigent, could go and get care. What are you doing about serving the least among us? David: I think that that’s an incredibly important part of what we consider our anchor mission strategy. And we’re in an urban core and we have to serve the population around us especially, but we’re really seeking to do more than that. So the partnership that has evolved with Sacramento County recently about expanding the services at their primary care clinic, it has evolved into not only serving and providing primary care but we have great plans to expand to become basically a specialty hub for fixing network inadequacy, meaning there aren’t enough specialist appointments for Medi-Cal patients, by placing our specialists in there with special permission from the federal government to do there because there’s a special reimbursement mechanism. And then to serve as a hub that is to support all the other clinics, the FQHC, federally qualified health centers, that serve the poor in their communities and actually allow them to access our specialists so they can do better care right in their own communities. And so we, I’ve talked to various people around Sacramento already about what’s the role that UC Davis could serve and best help the underserved communities, and that really is it. And so luckily with my colleague who’s now heading up health care services for Sacramento County, Peter Beilenson, we’ve come up with an aggressive but we believe really helpful plan to, it’ll be basically a nation leading effort to provide not only specialty care to the Medi-Cal population but also social services within our same building. We currently have help for people who might come around food insecurity, housing insecurity, legal questions, they’re all embedded now into the clinic. So we believe it’s a type of one stop shop that’s going to truly be a social good. Scott: Now you know, it’s interesting, as an aside I’ll tell you, when my grandfather was a physician in inner city Detroit and when I described his office, it was that it was a social service center that happened to provide medicine. Everything from adjudicating disputes to reading people’s documents and all sorts of other things. So it’s very interesting because it sounds like almost Back to the Future where it is that the physician or the medical clinic really was at the center of the neighborhood. David: Right, and that is frankly the way it should be. We really need to forge a much closer partnership with social services and public health efforts with the inner city organizations that are serving the nation’s poor and otherwise underinsured. Most of the time, we’re really good at prescribing the right pill but then we don’t realize that, well, we can give you a pill for your diabetes but where are you going to get healthy food? We’re going to get food that doesn’t spike your blood sugars. Where are you going to find a safe place to do the exercise that we’re telling you that you should do? Or an asthma child who lives in a poor neighborhood and they don’t have the right environment to control their asthma. We give them the right inhaler but not the right environment. So we really need to be partnering more so that the medicine we prescribe and the cures we wish to deliver are actually effective. Scott: It’s interesting because in touching all of those points of the human experience, it would seem that that would give you and your colleagues a very rich opportunity to look at how physicians are trained and other health care professionals and how they’re delivering services in maybe an expanded way from how it’s traditionally been done. David: You know Scott, that’s a great point. Although I don’t generally like regulatory bodies, our medical school is undergoing its every eight year accreditation within a couple of years and one of the challenges is always that we’re supposed to be updating our curriculum. And so we are in the process of doing just that and I have actually challenged our faculty, incredibly smart and great people who have taught medicine in a fairly traditional manner, to really think outside the box just like you were talking about, which is we need to train physicians not only how to memorize facts and deliver a cure but how to ask the right questions of their patients, maybe with a little more focus on social determinance of health. We need to teach our physicians how to aggregate information from multiple sources, not just how to read textbooks. We need to teach them how to use an electronic medical record so it’s not a burden but a tool in better care. And you don’t just wake up one day knowing all this, you have to be taught it and so we are really talking about integrating that all into our new curriculum as well as learning how to work in teams with our nursing colleagues and our pharmacists and our social workers. Again, that hasn’t been a traditional part of medical education but team based care of patients is the thing that is most successful. Scott: How has that team based approach changed how medicine was practiced when you first got your license? David: Well you know, when I got my license a long time ago, I’ve been practicing now for 35 years and when I was trained in medicine it was like you’re the captain of the ship, everything depends on you, you’re going to save the patient’s life. If you’re not there, you can’t trust anybody else. That’s a terrible way to train people. You have to enable, empower and educate your colleagues who work with you and by your side so that when you’re not there, there is no danger to the patient. As a matter of fact, they’re getting the exact same care as if you were standing by the bedside. Leading a team is all about making sure that the people on the team have all the knowledge and experience and support that they need to provide great care. And whether it’s a nurse or an advanced practice nurse, a physician’s assistant, a pharmacist, a social worker, all of these people can be incredible caregivers and do things that, frankly, as well as or better than the physician in some cases. But it is incumbent upon the physician to figure out what really requires his or her time. There was a study once that looked at how much of a physician’s hour is spent doing things that only a physician could do and it was something like seven to 10 minutes. Scott: That’s it? David: Yeah. The rest of it could be done, a lot of it’s done with entering data into the medical record. I mean good voice recognition software or a scribe that costs $15 an hour or something doing minimum wage work like a secretarial typist, they could alleviate and have a physician become so much more effective and efficient in their interactions with patients. So we just need to embrace this whole idea of more than just a doctor doing the care of patients. Scott: When you look at how it is that health care has evolved from a regulatory and policy standpoint over the past few years, from your vantage point where are the biggest dangers to the system in blocking clinicians and other health care providers from getting the patients what they need? David: There have been a couple of very interesting publications lately, one was in the Journal of the American Medical Association, how HIPPA, a great rule around patient privacy- Scott: Remind us all what HIPPA- David: Health Information Portability and Accountability Act. Scott: That’s that thing we have to sign when we come into the office. David: Yes, and what it says is you own your medical records and that medical record privacy is incredibly important and really ruled only by the patient. The thing is that in the pursuit of that, we’ve gone off track and made it difficult for clinicians across different systems, because you know you don’t only get your care at UC Davis, you don’t only get your care at Kaiser. You go from hospital to hospital sometimes, maybe you want a second opinion. The ability to get ahold of your own medical records and to efficiently and fully transport them to the next provider is really not fully established across the United States. And that actually causes redundancy in testing, it causes a hole in the way all the records are delivered so you don’t always get them and it’s really an impediment to getting as much information as you might want to your next provider. So I think that we really need to amend HIPPA and make it so it’s easy for patients to get the information that they need to the next provider and remove all those barriers. We’ve made that difficult. And the other part of this is also how we reimburse people. One of the things that Kaiser has done a great job on is that they’re able to do things that aren’t specifically reimbursable, things like generate peer groups for disease support or digital interfaces that aren’t specifically reimbursed because you start with a set fee and then you figure out what’s the best way to spend that set fee to provide services? In the traditional fee for service world where we live, we can’t charge for any of that. And so all that is is just an extra expense, so we have to figure out a way to move more patients, whether they’re in all of our systems, to alternative payment models where you get a set fee to take care of people and you figure out, “How should I spend my money,” and not all of it should just be spent on physicians. Scott: So one of the things that I’m most curious about is this, is that when, sort of doing a little bit of background, you’ve had an amazing arc to your career but where did it start? What inspired you to become a physician in the first place? David: Yeah, I hate to be kind of old fashioned and dowdy but it was my family practice doc making a house visit, who happened to be the grandfather of one of my best friends. The thing, sort of the Marcus Welby, he looked like Marcus Welby, carried a little black bag, came and, you know, I had the flu one day and he was feeding me warm Coke and couldn’t do much, but boy he made me feel better. And I realized at that time that I wanted to be a doctor and that was when I was about 10 or 12 and have never wavered. Scott: One of the interesting things, you tend to get involved in some interesting little sidelights and one of them is, I came across a writing by you where you provided some expert testimony related to the use of particular agents with lethal injection. And I don’t know the exact specifics of it but what was that all about? David: Well, so let me just be really clear about this, talking about this, I don’t represent the University of California in this in any way, shape or form, but my own personal research was about, in 2005 I published an article in the Lancet which is one of the leading journals in England around the use of various anesthetic sleeping drugs for the purposes of lethal injection and the fact that they were inadequate and that was published when I was at the University of Miami almost 15 years ago. And that was one of the things that led to the current debate that has been raging over whether or not lethal injection is cruel and unusual punishment. I do not have an opinion about the death penalty nor do I espouse one but I do serve as an expert witness around how anesthetic agents work or don’t work in the process of lethal injection and have been involved in a couple of Supreme Court cases that have, of great interest I think to the American public around how we dispatch convicted inmates who have gotten the death penalty. And I think that we could do a lot better job than we do. Scott: On a slightly lighter note, you come here from a place that’s known for lots of entertainment, lots of activities and so you’ve now come to the land of farm to fork. What is it you’re enjoying most about this region and what do you like to do when you’re not running this nation state? David: Well, it is a big organization. As you know, UC Davis now about three billion dollars a year, so that does take up a good deal of my time. And what I really would like to do outside, first of all I love to eat, so the farm to fork thing is super. I am a wine collector from way back. I have several wine making friends who are in Napa, envious. One day maybe I would like to learn to do that, but being close to the vineyards to me is a great opportunity. My love, though, is road biking. I just love to get out there, a little need for speed, and even though I’m getting on in years, the sort of non jarring exercise part of road biking, that’s a really good. Scott: Is there a non jarring part of it? David: Yeah. It’s a little better than running for me. Scott: All right. Well, we’ll look to see you out on the bike trail. Thank you. And that’s our show. Thanks to our guest and thanks to you for watching Studio Sacramento. I’m Scott Syphax, see you next time right here on KVIE. ♪♪ James Beckwith: At Five Star Bank, we create thoughtful solutions to help the capital region thrive, from economic development and education to public health and safety, issues that are vitally important to Sacramento’s prosperity. We’re proud to be part of the conversation and hope you’ll join in. Annc: This Studio Sacramento episode is supported by UC Davis Health where doctors, nurses and researchers share a passion for advancing health. Learn more about their latest medical innovations at health.ucdavis.edu. Annc: All episodes of Studio Sacramento along with other KVIE programs are available to watch online at KVIE.org/video.