Podcast Episode Transcript: Biking 3,255 miles to talk health care

With L. Gordon Moore, MD

Gordon Moore: Welcome to the 3M Inside Angle Podcast. This is your host, Gordon Moore, and today I’m talking with Dr. Paul Gordon, who is a tenured professor of family and community medicine at the University of Arizona. Welcome, Dr. Gordon.

Dr. Gordon: Thank you for having me.

Gordon Moore: The reason I thought it would be fun to have a chat with you today is that I had an opportunity to hear you on a panel at the University of Rochester Family Medicine 50th reunion of the family medicine residency, and you talked about a cycling trip across the country where you were interviewing people around health policy and things that were interesting and meaningful to you. That just captured my attention. I thought that was fascinating because I like health policy; I think it’s cool stuff. I’d love to hear how this came about. Where did the idea come from?

Dr. Gordon: A little bit of a story, of course. I think I first considered or planned to bicycle across the United States back in the bicentennial, 1976, and I was unable to. For the next 40 years I kept saying, “I really need to do that.” My wife, children, and I were in the backcountry in the Grand Canyon doing some backpacking, and once again I said the same thing: “I really should just bicycle across the country.” The family, in their wonderful means, just said, “Shut up and do it already.” What a fascinating idea. Just do it. I said, “Okay.”

Then I realized that one of the very special benefits of being tenured is the opportunity to take a sabbatical. As I’m sure you know, family docs aren’t the classic folks to get sabbaticals. We don’t spend time, necessarily, in research labs across the country and the like. I think that the research lab for family medicine is people. We talk to people. We listen to people. We understand things related to that. As I began to think I’m due for a sabbatical—and a topic that’s of interest to me is healthcare policy—at the time, the planning was in 2015. The trip was in 2016.

Certainly we had heard more than enough about how much people hated the Affordable Care Act and indeed there had been quite a lot written about people’s distaste for the ACA. Yet it was all based on surveys. I thought maybe I could add to that body of knowledge through conversation. I then said, “What better opportunity than my sabbatical? I’m going to ride my bike across the country and listen to people about the Affordable Care Act.”

I used the word “listen” very specifically because indeed I called this the Bike Listening Tour, and I made as part of my research methodology that I would only listen. I would not correct. I would just acknowledge, but never tell someone that what they said is wrong. As I’m sure you could imagine, there was lots of misinformation. I feel very confident that, having kept my mouth shut as we family docs are capable of doing, I had enormous amounts of information shared with me. That was clearly the key to the success of this trip.

Gordon Moore: I’m always impressed by the degree to which a comment or jumping in the middle can shut down the natural flow of conversation. I get nervous about that even in these interviews. You’re doing great, but I’m thinking about what a challenge that is as you travelled across the country on a listening tour. How in the world did you do that? How did you come up with the idea that this was going to be useful?

Dr. Gordon: I considered it to be useful because I think that survey data is important, but more detailed conversations with people enrich the dialogue, enrich the content that we own in such an enormous way. That’s how I came up with the listening tour idea.

You asked how I did it. What I would literally do is create a jersey. I realized that one of my first cousins was a graphic designer and I asked her for some help. I put together a jersey concept; she turned it into a formal graphic. We sent it to a bicycle jersey company and I got these jerseys made that said “Bike Listening Tour.” It had a graphic of the country with a line across—my biking. I would walk into a café, a gas station, a little place where people were hanging around—I’d walk up, introduce myself. “Hi. My name is Paul Gordon. I’m riding my bike across the country.” I would point to my jersey. “As you can see, I want to know what you think about the Affordable Care Act or Obamacare. Talk to me about Obamacare.”

Many times people would say, “No. You don’t really care what I think.” I’d say, “Absolutely I do.” What do you think they’d say? I said, “No. This isn’t about me. I know what I think. I want to know what you think.” We’d have a bit of this back-and-forth for a while. A couple people thought that the president was actually paying me to ride across the country to change people’s opinions, and once I reassured them that none of those things were actually correct, that all I wanted to do was hear them, they opened up and they opened up in a very big and candid way. I had over 125 conversations between Washington, DC and Seattle, Washington which were fascinating and wonderful.

Gordon Moore: You would stop somewhere for lunch or what ever and you’d run into somebody and say, “Hey.” That’s how you met folks?

Dr. Gordon: Absolutely. The interesting thing is that as I was planning for this trip, my wife, who had a real job—she actually had to see patients—was only able to come with me for one week. She didn’t have the luxury of taking three months off of a sabbatical. She said to me, “Paul, you don’t talk to people. How are you going to be able to do this? You’re way too shy. There’s no way you’re going to do this.” Quite honestly I don’t know how it happened. I got into a rhythm. I got into this place where I felt perfectly comfortable walking up and saying, “Hi. My name is Paul. Tell me about Obamacare.” It just really worked. It was amazing. It was also some of the three best months of my life. It was unusual.

Gordon Moore: Tell me something about what you heard.

Dr. Gordon: As I mentioned, we’d have conversations ranging from 10 to 40 minutes. I kept notes—kind of extemporaneous field notes. After each encounter I would make a dictation into my cell phone, and every evening listening to the cell phone I would write—I did it on a blog site, WordPress, and then I kept a formal copy of each of those write-ups and went through those write-ups in a more qualitative research method to identify themes and codes.

I came up essentially with four major themes. They included: people felt that the ACA had increased the cost of health insurance, they felt that the government shouldn’t tell people what to do, they felt that the responsibility for all of the ACA problems was rather diffuse—of course, blaming congress, and many people blamed the president. The last theme was the one that surprised me the most. The first three were really not a surprise—I was anticipating those things—was that the ACA shouldn’t pay for other people’s problems.

For instance, I met a barkeep in western Pennsylvania, a woman probably in her 50s. She said, “Why should my money go to pay for someone else’s pregnancy?” I kept a straight face, thinking she had just in the previous conversation told me about her children and how proud she was. I was thinking, “You were pregnant one time. Who paid for your health care?” The idea of the shared responsibility of health insurance. Anyway, that really struck me. There was a lot of other-ism and there was a lot of “I just don’t want my money to help anyone else.” That was probably the theme that was the most troubling for me.

Gordon Moore: You touch on a relatively obvious thing, which is the essence of insurance and how that works, but I wonder if over time, possibly even those listening to this podcast might have forgotten about that. Give me a thumbnail sketch of your thoughts on that.

Dr. Gordon: That certainly points me to the future as I am working toward a Medicare for all approach, but the point being that, as with any insurance, we spread the risk. We are all obligated to purchase car insurance whether we want it or not. It’s the law. The fact that I’m a crappy driver but you’re a very safe driver allows my premium to be a little lower than it would have been had I been the only one insured. Similarly with health, if we can spread the risk across the largest number of people, then we can keep the premium down.

I would have an opportunity at times to say I’m faculty at the University of Arizona. I don’t know how many employees we have but I’m sure it’s over 10,000. The fact that the health insurance premiums are spread over 10,000 people as opposed to just 10 or 20 allowed me to have some pretty serious heart surgery, which I think was in excess of a quarter of a million dollars, be covered. My premium doesn’t change even though I obviously had disease.

Gordon Moore: What it gets for me is this concept of the greater good for a community, a society that if we all collectively pay in and I pay a bit more than I necessarily need, it could benefit another person, but it’s a net good. You get to keep teaching at the University of Arizona and that’s a good thing, generating physicians who are going to go out there and practice, which does a good thing for our community.

For me to say, “I’m living healthy. I’m not like Dr. Gordon. He led a terrible lifestyle so he should take care of his own costs.” I have that sense that our country sort of drifted a little bit into that “I’m looking out for number one here, which is me, and to heck with everybody else.” In that sense, it’s ungluing our society and that may not be in our own best interest, even though I may be paying a little extra to cover your heart surgery.

Dr. Gordon: I think that’s a very good point you brought up about shared responsibility, which I’m afraid has eroded in this country. In the end of one of the manuscripts I wrote, I talked about Germany, where their health minister at that time, Ulla Schmidt, had the concept of social solidarity—that everyone in Germany should have guaranteed access to state of the art medical care and contribute to the financing. That was the idea of shared responsibility, and I think since insurance in general covers the unexpected—you don’t plan to have a problem—then we do have to see it, I believe, as a sense of shared responsibility to be able to take care of each other.

Gordon Moore: It’s very similar to the concept of the greater good of having an educated workforce. An educated workforce means that our nation can be preeminent in the world potentially on devising new software, making cool new things that help benefit people. Obviously we do some other stuff, too, but there’s that fact that I’m paying taxes on education but it’s benefiting me in the long run because now I have the internet, which I didn’t figure out, but somebody else did because they had a good education too. That’s a cool thing. You ran across the country, you interviewed a lot of people, you were asking all these questions. What did you do with that information?

Dr. Gordon: One tiny correction: I didn’t ask a lot of questions. I pretty much asked, “Talk to me about Obamacare.”

Gordon Moore: You asked the same question a lot of times?

Dr. Gordon: Yes, because I didn’t have a script of 10 questions that I had to get through. I think that made the conversation essentially easier and it allowed it to flow. I didn’t have to keep looking at my little pad to say, “I have to get to question three. I’d better hurry up and get to question four,” and the like. It was really an unstructured conversation, so that really made a difference.

Regarding what I did, as I mentioned, I spent each evening writing up the encounters we had that day, and one of my students, Laurel Gray, who’s now a pediatric intern in Salt Lake City, came on this trip with me, as did some others. She came as part of her summer research project between years one and two of medical school. She had a good background in anthropologic and qualitative research, so she really helped in this idea we mentioned before about identifying themes and codes for all of the 125 interviews, and then we wrote them up in manuscripts.

We got three things published at the time, and just recently, David Sklar from academic medicine asked me to write a reflection on the 2018 election based on our trip—so as far as an academic was one of the most productive periods of my life, having three or four manuscripts over three months. One of the manuscripts was called Opposition to Obamacare: A Closer Look. That was really the biggest manuscript. That was a pretty nice piece in academic medicine back in September of 2017.

Then I had written a piece that got published much earlier, in October of 2016. The editor had asked that I try to write something about “What can physicians do regarding healthcare policy?” I wrote a short commentary about that. Then I wrote what was really a lot of fun for me: a reflective narrative essay about bicycling through American heartland. That was in the journal for the American Board of Family Practice.

Gordon Moore: Very nice. Having gone through all that, is it the kind of thing you would ever do again?

Dr. Gordon: Absolutely. If I could back up one second, there was not uniform anticipation of success. Not everyone that I worked with here in Arizona anticipated that it would result in actual publications and the like. It surprised a few people, which was great for me, because I knew it’s a sabbatical and I have to create, I have to share the knowledge that I gained, and it wasn’t in someone’s basic science research lab. It was in our family docs’ research lab called the country at large. I was just very excited to be able to produce those writings and to get them published in really good journals.

Would I ever do it again? Absolutely, and I’m planning to do it again in the summer of 2020. We’re going to cover some of the same route. We’re going to go through Pennsylvania, Ohio, Michigan, Wisconsin, and Minnesota. Many of the places that we remember from 2016 voted for now president Trump, and I’m anticipating there will continue to be some misunderstanding or the like about healthcare, and this time the conversations are going to be focused around healthcare policy. Tell me what you understand of Medicare for all. What is a Medicare for all lite? What is a public option? What is the market-based approach? What is socialism? What is the Canadian approach?

This trip I’m in the current planning stage—is going to be a little different in that I think I will like to take the next step from just listening to try to understand where those things come from and how those values around healthcare would translate into their anticipated vote in the 2020 election. To the extent that I find that there’s a mismatch between their hopes for universal coverage and the ability for children to remain on their policy and keep premiums down and all of that stuff, yet they plan to vote in ways for politicians that have in no way shared those values, I’m going to try to explore where did that come from and see if I can understand that.

Gordon Moore: Is your intent to change the way they’re thinking about voting? Is it an intervention, or is it just listening for that next layer of where to come from?

Dr. Gordon: I am hoping it will only be a listening. I’m not a politician. I am not running for office, nor am I campaigning for anyone else running for office. I’m hoping that at the end of the discussion people can just understand what I talked about. My wife does a lot of reading about this as well and she’s going to come on the next trip. She and I wrote an op-ed piece in our local newspaper about myths about Medicare for all. What came about is that we tried to clarify some of the myths that are out there. People I work with look at the local newspaper and say, “Hey. That was a great piece.” Even people I know don’t agree with me at least acknowledged some greater understanding of what we wrote about. If I could accomplish that same thing I’d be perfectly happy.

Gordon Moore: How long do you think this trip will take?

Dr. Gordon: It will only take as long as I have off between sessions. School ends May 16th and school begins about the third week in July, so I’m planning to finish up the research part in early July, and then hopefully the last week and a half my wife and I will just take a vacation and either go over the Rockies in Montana or over the Cascades in Washington state.

Gordon Moore: Wow. All depending on how fast you’re making tracks.

Dr. Gordon: Actually we’re going to finish the research at the beginning of July in Fargo, North Dakota. The town was picked for two reasons. One, I anticipate it will have bus stations and airports. Second, we like the movie Fargo and just before we get to Fargo we’re going to be going through Bemidji, which as you probably know was the site of the TV version of Fargo. That’s a little side twist, but we’re going to get to Fargo, and then from Fargo we’ll grab a bus to get to Montana or to Spokane, Washington and finish the last part of the trip. We’re not as many miles this trip.

Gordon Moore: One of the questions that occurs to me a lot is the understanding of healthcare policy at a federal or state level and how that impacts a person’s life. One of the things that keeps coming to my mind is the framework for understanding quality in healthcare and how micromanage-y and granular it gets when it says, “You, doctor, need to test a person with diabetes, with X, Y, and Z, and achieve these things.” Then to support that, the medical record companies are embedding all these pull-down menus.

Now I hear from our colleagues that they’re just banging their head on the wall with frustration about all this minutiae they have to capture which is getting in the way of doing things that really matter for the people who were coming to them for care. I’m thinking this well-intended policy—let’s measure quality—got so twisted and weird that it’s actually getting in the way of quality and dragging a lot of clinicians into misery. That’s that fascinating thing of what really matters to us and how does it manifest in this really awkward, unintended mess, and how can we change that? That’s where I’m coming from, and it sounds like you’re on a similar path.

Dr. Gordon: I absolutely agree with you, and at the risk of being critical, I think this whole push towards measuring quality is just an opportunity to duck. Instead of doing what would really address healthcare costs, they’re making believe that if we penalize doctors for not doing the right things we’ll save money. Unfortunately, as you mentioned, this junk keeps us from doing the right thing, which is taking care of our patients.

I’m a very strong supporter of Medicare for all. If we are to remove the enormous amounts of overhead and profit that goes to the private insurance industries, we’ll have more than enough money to not only introduce a Medicare for all but a modified Medicare for all, which means we wouldn’t even have the schedule D and the drug piece. We wouldn’t have the 20 percent gaps and the Medicare advantage, who are also cherry-picking and taking advantage of the consumer. We’d have the ability to pay for all of that. We just wouldn’t have the private insurance for profit industry involved.

I would hope then, without having to spend so much of your time and energy around administrative garbage, as I’m sure you know from people you’ve spoken to, those in practice—they have to hire a handful of people just to handle insurance. Without having to do that, then maybe all they’d have to do is take care of patients, in which quality would inevitably improve if that’s the only thing they were focusing on. That’s my little soap box.

Gordon Moore: Tell me what you get to do when you’re not riding a bicycle across the country and planning your next ride. What do you do during your typical day job?

Dr. Gordon: I’m very much involved in education here at the University of Arizona. When I started a little over 30 years ago I was mainly focused on resident education, and as I progressed over time I’m now more focused on undergraduate medical education, so I teach in the first couple of years from a medical school curriculum in a block that I lead called The Doctor and Patient: Integrating the Art and Science of Medicine, in which we teach our students to perform a medical interview, a physical exam to learn to make an oral presentation, to do the write-ups, and most importantly, issues around clinical thinking and clinical reasoning. How do we go from a patient’s symptom complaint to ultimately a diagnosis? I’m very fortunate to be able to spend so much of my time teaching, which is really what I like.

Gordon Moore: That’s a lot of fun. I think about all the opportunity there in helping the future generations get beyond just the physiology, which is important, but there’s so much more to people as we’re talking to them, learning how to interact, learning how to understand that complexity. Use standardized patients in your work?

Dr. Gordon: Absolutely. We’ve been doing that in Arizona long before I got here, probably more than 40 years now. I direct our standardized patient program here in Tucson and we’ve been using our standardized patients for undergraduate medical education, for graduate medical education. We’ve done some research projects with unannounced patients going into the community to measure intense various things. We have a health sciences center here with nursing and pharmacy, so they come and do standardized patient activities as well. I’m very pleased and proud of how much we do here in Tucson with standardized patients. I have the privilege to run that show.

Gordon Moore: Why do you think it’s important to have standardized patients? Why not just let the med students learn with real patients?

Dr. Gordon: You mean like we did? I think the real advantage of standardized patients is the opportunity to take risks in a safe environment. Before you’re going to ask your patient about some sex, drugs, and rock and roll, which could be a very challenging area to talk about, we give the students an opportunity to practice in a much safer environment with trained patients.

The next week or the week after we’ll go back to the hospital and we’ll do those same questions, and similarly with physical exam maneuvers, most notably breast, pelvic, and male GU exams—I think are very important—that when you go to see a patient and the patient looks at you and says, “This is the first time you’re doing that?” “No. Not at all,” the student can say, because they’ve had practice. I think it’s more respectful to our patients that some of those difficult tasks we expect of our students to perform, they’ve actually had an opportunity to perform them before in an environment where they can make mistakes.

Gordon Moore: That’s a very nice framing. I heard recently about some research with surgical residents where they’re going through very challenging scenarios in an environment with standardized patients around. For instance, having a discussion about something that went wrong in the OR or a bad prognosis and then having that discussion with a challenging family member, or difficult dynamics. I like that. Do this in a safe environment because you know you’re going to be facing that tomorrow when you go out on the floors and see patients. That’s good.

Dr. Gordon: We’re all human beings. There’s no reason we should suspect we are born with this skill set. We have to learn it, and if we’re going to learn it, let’s practice it first. I’ve heard about those surgical encounters and we’ve tried to do similar challenging communication scenarios, we call them.

Gordon Moore: Sure. As we wrap up, are there any last things you’d like to impart?

Dr. Gordon: It’s still in the planning phases. However, I’m working with one of the documentarians from our film school here at the university and we’re hoping to create a documentary on the next trip in which we’ll have the opportunity to engage even more deeply. A documentarian knowing about the importance to show a character in the film as more than just 15 minutes of questions and answers, but we’ll have the opportunity to go back to their house, learn a little more about them, show the human side of who they are as opposed to just the opinion that they had about Medicare for all or something like that. I’m really excited. We’re looking forward to it—need to do a little fundraising, but I hope it will come to pass.

Gordon Moore: Interesting. That sounds like a lot of fun. We’re going to provide a link to some of the videos from your last tour and maybe that links to your upcoming one as well.

Dr. Gordon: That would be great.

Gordon Moore: Dr. Gordon, thank you so much for your time today.

Dr. Gordon: It was really a pleasure.

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