KERCasts

The Nation sets its eyes on patients living with many ongoing conditions

November 19, 2020 KER Unit Season 1 Episode 6
KERCasts
The Nation sets its eyes on patients living with many ongoing conditions
Show Notes Transcript

Join Dr. Victor Montori as he speaks with Dr. Arlene Bierman, director of the Center for Evidence and Practice Improvement at the Agency for Healthcare Research and Quality (AHRQ). In this lively discussion, Dr. Bierman shares insights from the many hats she has worn during her distinguished career, which include primary care physician, health services researcher in both government and academic settings, and advocate for equitable access to high-quality health care in the United States and Canada.  

Victor Montori:

It's time for the KERcast brought to you by the Knowledge and Evaluation Research unit at Mayo Clinic. I'm Victor Montori, your host for this KERcast. And today we are in for a treat. Arlene Bierman, Dr. Arlene Bierman is with us. She leads the CEPI, which is the Center for Evidence and Practice Improvement at the Agency for Healthcare Research and Quality of the United States government Arlene is a general internist, and geriatrician, a health services researcher. Today, we're going to be exploring a range of topics in the fashion that we have follow here at the KERcast. But we are very lucky to have here, Arlene, thank you for joining us today.

Arlene Bierman:

Oh, hi, Victor. Thank you.

Victor Montori:

So the first question that we always ask in these things is how how does one become Arlene Bierman? What's, what's the journey like? Is it something you chose to do when you were, when you were little and you followed a straight path? Or has it been a convoluted path? A mixture of choice and chance?

Arlene Bierman:

Yeah, well, I can say I've taken the scenic route, which has been nice. So I was born in Brooklyn, New York, my family was living in the projects at the time I was born. I grew up working class in Queens, and it was the first person in my family to graduate from college. But I was very lucky, having been born in New York City where we had access to, you know, good public schools at the time. We had museums and the Philharmonic in the park and great libraries, Shakespeare in the Park. So I had lots of advantages, even though our means were were pretty modest. Um, so anyway, that's, that's where I came from.

Victor Montori:

And how do you end up where you are now? I mean, did you choose to be in government? How is that, how did that happen?

Arlene Bierman:

So I've done many things across the course of my career. When I graduated from medical school, I actually went back to my old neighborhood in Queens, where I practiced, I practiced for over a decade in the public hospitals in New York City, I ran the department of ambulatory care there and a primary care Internal Medicine Residency Program. I've also, you know, I'm working in government now, I did a stint in government before and I've also been an academic. So I've taken a couple of different paths in my career.,

Victor Montori:

And what has, what has motivated those, those paths? Is it, is it just, you know, opportunities that you chose to take? How did you navigate all those paths?

Arlene Bierman:

I think you know, one thing you know, went into another, um, I always wanted, you know, I, I clearly, you know, returned back to New York City to take care of people who were, you know, underinsured, poor, uninsured, because that was my, that's what motivated me to go to med school. Um, and then I quickly learned that, you know, there's all kinds of challenges within the health system. So there was a lot, I wanted to contribute to fixing them, and making care higher quality and more equitable. And just, I think, you know, just being open, willing to take chances, and, you know, seeing what comes along is how I got here.

Victor Montori:

Many people say that they went to medical school to help people, but then a lot of people must have forgotten that, right? I mean, how, you didn't?

Arlene Bierman:

Yeah, well, I think I you know, there's powerful, you know, socializing forces in medical training, and I think it is challenging to resist them. But for me, it was always key to stay, you know, close to who I was, um, and, you know, maintain certain values and knowing, you know, knowing the reason I was going into medicine, which was really, it was to help people of course, but also to help communities and help increase, you know, access to care for people who were challenged.

Victor Montori:

Was the, was the bedside not enough to do that?

Arlene Bierman:

Um, it's important. It's important and I love practicing and it was pretty cool. Working in Queens in my old neighborhood. You know, I would run into my patients in the, I lived in the neighborhood and I would run into them in the fruit stand. I remember a diabetic saying, "Look", with his wife, "Look we're buying vegetables and fruits". And I said, Oh, that's great, you know? So yes, there's I think there's a lot of rewards in the practice of medicine, of being able to help people one on one, but also very enriching learning people's stories and learning a lot about life. Um, one of the things we did, it was very interesting, um, in, we were asked to do quality improvement, which I knew nothing about. And, you know, as a team, we decided, Okay, what is the biggest problem, and we were all tired of seeing women come into the clinic with late stage breast cancer...

Victor Montori:

This is, this is in Queens?

Arlene Bierman:

This is in Queens, half of our patients were uninsured. Um, you know, and then the rest were a mix of Medicaid, and Medicare. And, and we actually did find that there were a sizable number of people with private insurance, and they just thought we were good doctors. So they didn't tell anybody. They came to see us anyway, we didn't collect, because they didn't tell us they were insured. So we fixed that. But so but our patients were from all over the world, it was the most ethnically diverse zip code, actually, in all of the US, from 110 countries. And lots of people also who were not exposed to preventive medicine before. And we all work together we work, you know, with the clinicians and nurses, we had standing orders, why this was important. We had videos in multiple languages and handouts in the waiting room. And within a year, we had rates of mammography screening of 80%, higher than the best HMOs in this very challenged community. And I think at that time, I realized, oh, maybe we didn't do it in a research way. We just kind of thought about what what would it take to fix this? And sort of, at that point, I decided I wanted to go back and get research skills and learn how to do this in a way that was more generalizable.

Victor Montori:

And where did you do that?

Arlene Bierman:

At Dartmouth.

Victor Montori:

That's an okay place, right?

Arlene Bierman:

Yeah, it was alright. I got a master's in health services research and I learned how to work with big databases.

Victor Montori:

And how was that experience of going from I mean, many, many researchers, sometimes to a fault, seem disconnected from the realities on the ground, particularly health services research that, that see the world through databases and through the data. But, but having had the experience of being on the ground with patients and with clinicians, how did the experience of going from the ground and trying to improve things on the ground, to the you know, the distance of the classroom and of the database. How did that fit you?

Arlene Bierman:

So, you know, that's an interesting question, Victor, it was, it was, it was a marvelous opportunity, I learned so much. And I did, I found out I had a, you know, passion for working with big, you know, databases, secondary databases, which I didn't know before. But I should say, I went in there with a very clear goal of why I wanted to learn the research skills. And it really was how do I do research that could really advance health equity, and improve access to care and quality of care for people who, you know, I think the COVID epidemic has really brought home, how disparate our health system is, um, you know, we have the best care in the world, and then we have the worst care in the world in the same country. Um, I should say that, you know, when I was studying at Dartmouth, at that time, I was interested in health equity, which has become very trendy a lot of attention to it. Nobody was interested in it at that point.

Victor Montori:

How come? I mean, how could they have been so disinterested?

Arlene Bierman:

So, I think it's, I think it's the work of a lot of people, a lot of researchers who in aggregate, have educated people and have documented the magnitude and the relevance of the problem. And it was interesting, I was thinking about becoming a researcher and kind of a little discouraged that nobody was excited about the questions that I wanted to research. And I actually listened to an interview with Martin Scorsese, and Hollywood, and he said, Well, you know, I'm from a different place in my, you know, my movies are about that place. So I just said, Okay, I'm from a different place, and my research is about that place. And, and, you know, I've continued to really having spent over a decade you know, in the trenches, I think still informs my research. You know, I am so glad that I've had that experience.

Victor Montori:

And and I presume you discovered that there's plenty of room for women in academia.

Arlene Bierman:

Oh, let's not go there...

Victor Montori:

Come on. We have to go there. It is a major challenge, isn't it? And and I think it's very hard for women to have successful careers as judged by, by academia, successful careers in academia. Right. Was that evident at the time you went through it?

Arlene Bierman:

Oh, yes. You know, I think there's lots of bias, you know, um, but I just really kept my focus on what I was doing and why I was doing it. And, you know, no, you know, I knew there was bias in the world, right?

Victor Montori:

Yeah, yeah. Well, you, you were experiencing it from the clinic. How did you, so once you once you were armed with those, with that research, armamentarium, so to speak, did you go back to Queens?

Arlene Bierman:

No, so this is funny. I did. I, you know, my plan, initially, was to, you know, get the research training and go back to Queens and keep doing what I was doing. Um, and then I got it kind of got derailed along the way. I think, well, there were two things that happened. Um, one was New York changed a lot. You know, I was doing in in Queens, we were doing community oriented primary care, things that people are talking about now. So I think it's, you know, going back to the future.

Victor Montori:

Yeah the pendulum.

Arlene Bierman:

My first grant was from the United Hospital Fund, which really developed a strong partnership between the hospital and community based organizations in our community, we were working on setting up family health clinics as satellites. I actually established the first Family Health Clinic in a New York City public hospital, so we were doing all kinds of cool stuff. But um, you know, the governance in the city had changed, um, where that wasn't as well supported, and actually leaving New York and I had two young boys at the time, I realized that there were better places in the world to raise kids. So I ended up not going back.

Victor Montori:

Where did you go?

Arlene Bierman:

I ended up going to AHRQ. So I spent a stint at AHRQ and I never, ever thought I would go to government. So I think it's like kind of just being passionate and being curious and being willing to take risks. I actually had been offered a job of, as chair of preventive medicine in a in a major medical school. And a good friend of mine, I had turned down AHRQ, and a good friend of mine said to me, are you crazy, you think you're going to run a department, teach, see patients, and build a research career? And at that time, I was offered an intramural research, position and AHRQ, they had those in those days. They said, take that, you know, to get paid full time to do research, you know, and actually, it turned out to be one of the best jobs in my life. And I loved it, I worked. I actually had two hats. When I was at AHRQ, the first round, I was a intramural researcher, you know, focused on both health equity issues and disparities, as well as on, you know, patient reported outcomes, functional health outcomes in older people with chronic disease. So it's kind of split. But I was also a senior advisor on aging to John Eisenberg, and I worked very closely with him. And he just taught me so much and just made me think I could do a whole lot more than I ever imagined, you know, that I had not thought about doing.

Victor Montori:

It's interesting. Every time I've met anybody that met John Eisenberg, which I haven't, I didn't get a chance to meet. Everybody that talks about him, speaks highly of him as somebody that was able to build AHCPR and then AHRQ. And to do so with enormous mystic and great capacity for mentorship. Is that an accurate depiction?

Arlene Bierman:

Oh, absolutely. I wrote a paper with him on I called it the paper from hell on collecting racial and ethnic data, that was eventually, you know, published in Health Affairs, and he would give me you know, drafts back correcting my grammar and my commas, and I felt so embarrassed, but he taught me how to write and he taught me how to write about sensitive issues, because at that time, you know, collecting racial and ethnic data wasn't, you know, acceptable, like it is now or assumed. And to you told me how to write about issues that might be sensitive in an, in an objective way that could, you know, educate people why it was important.

Victor Montori:

You know, listening to you one gets the impression of local and regional government and then federal government having roles in, in giving people opportunity to get exposure to culture, to services, to care, to education, and government as a force for innovation and advancement. We don't have that picture of government every day, but you eem to have experienced it firs hand?

Arlene Bierman:

No. And you know, it's like, you know, once you know, now I'm here, nobody would know, like, what, where I came from or my background. And I think about that, like, I grew up in a really golden age of New York City. And you know, you know, the access we had, you know, to culture, but also you know, what free tuition in the universities, as well as, you know, one of my first jobs in healthcare, I was working the midnight shift in a fast food, hamburger restaurant underneath the the Triborough Bridge, and I got an urban core job. And with that job, I was able to work, I worked as a phlebotomist, a lab tech, respiratory therapy aide, and that actually, you know, kind of reaffirmed my motivation to go on and study medicine.

Victor Montori:

Yeah, and then, and then, in your first stint at ARHQ, you know, bringing attention to important issues innovating science, about you know, how to write about these issues of, for instance, race you know its, government employees at the forefront of science. You know, sometimes we forget about that,

Arlene Bierman:

Yeah no, I mean, I never in a million years, like thought I would end up in government, but I don't know, if you read the fifth risk by Michael Lewis,

Victor Montori:

It's on my list.

Arlene Bierman:

Well, anyway, you know, I kind of was annoyed at the book, like he goes into, you know, agriculture, and you know, some of the other science, energy, and he finds all these amazing scientists doing all this amazing work. And it's like, well, you should know, that's what government can do for people. And they're are, and I mean when I look at, one of the things I love working about at AHRQ is just the smart people who are there, and people will come to AHRQ and come to government because they're passionate, committed, and they will and they want to make changes and they want to contribute to change.

Victor Montori:

Bright brains with the heart in the right place. I for full disclosure, Arlene was my boss at at AHRQ for, I had the opportunity and the pleasure and the honor to be a Senior Advisor for AHRQ for a few years. And and that was my experience, which is a, the opportunity to interact with bright people with, that wanted to make a difference, and that they had chosen a government opportunity to actually make that difference. It was extremely inspiring, and, and I, and they were, of course, working under your leadership Arlene, so that was very inspiring to see. If you were to, if you were to think about, and we're not yet finished with your trajectory, because that was your first time at AHRQ. But if you were to think about what is the primary value that animates your choices in your career? What would that primary value be?

Arlene Bierman:

I think I've alluded it, to it, it's equity. I mean, you know, I think the, the consequences of income, and racial and ethnic inequity in our country is really, in front of, we can't ignore it anymore. But that, you know, and you know, the hardships in people's lives that are unnecessary, as well as the loss to society of all these people who could make amazing contributions, you know, so I think, you know, just feeling part of a community. You know, as a researcher, I really felt strongly that I was part of a community who were publishing, who were writing about equity issues, writing about disparities, writing about better ways to deliver care, and even to change things. It's it's being part of a community who could put all this evidence together, that eventually adds up and makes changes.

Victor Montori:

Yeah, it's a it's a, it's a beautiful community. But it's, it's correct me if I'm wrong, I, I have a have a bit of a weird perception of the, of the health services research community, I think, on the one hand, you know, it's described very well, if we were to think of people like you, but there's also a another set of people who perhaps are newer to the field, who are enamored with the data, you know, some of them in fact of carry titles like data scientists and so forth. And they're, they're dealing with massive, massively large data sets. And they are able to do you know, incredible feats of alchemy with them with algorithms and, and computations that are, you know, hard to follow sometimes. And just, you know, I wonder if my jaundiced view of that is as similar to perhaps the the old expression of armchair epidemiologists, right, that there's a bit of a disconnect between the reality that is perceived through the cloud of data and the reality that you've seen, for instance, in the streets of Queens. Do you have a similar sense of that? Or are you more optimistic?

Arlene Bierman:

No, absolutely, um, uh, yeah, I think that first of all, I actually once wrote a book chapter on how to analyze secondary data. So I am a total data nerd. And I totally appreciate the value of data. I'm working on a project at AHRQ on developing algorithms to identify frailty, and, you know, so you know, in claims, in EHR data in partnership with ASPE. So this is something you know, I enjoy, you know, and I see the power and value, I think we do need data. But when I wrote that chapter, the first thing I said is, you have to start with the question and not with the data. And you really have to understand what the data is representing. So, you know, I think we can just there are people doing that. And I think we just need to encourage that, that. And I think, you know, taking the data in isolation, without understanding what's underpinning it can sometimes lead to misleading conclusions,

Victor Montori:

Within the spirit of your primary value, there's also this increasing recognition that, that the data that is then used to answer questions, that data itself was produced by individuals and systems that may have significant biases, discriminatory practices, that then manifest in the data and then carry on into the research, right?

Arlene Bierman:

Yeah. So I don't know, if you, another book, I highly recommend, it's a book called weapons of mass destruction. I don't know if you've heard that one. But it really talks about all the pitfalls of using data without critically understanding what, you know, the biases in it, and and what it's doing.

Victor Montori:

This this year's Academy Health keynote spoke about the other challenges which are not mathematical or not, you know, algorithmic, that have to do with the, you know, further discrimination of folks on the basis of who contributes and how they contribute to the data and who decides what data then gets to be included in analysis. So there is a threat to equity, you know, through through data, which...

Arlene Bierman:

I'll tell you a story about that, I think more and more, we need mixed methods to really validate what the data is telling us. And we didn't talk about my stints up at University of Ontario, and in Toronto. I was a PI for a large study that did a health equity report for the province of Ontario. And we use a partnership community engaged approach in the context of this big data project. And we got some people together to you know, get input. You know, we both had experts like technical expert panels, but we got the community to tell us what we should be measuring and help us select our indicators. And when they looked at our access indicators, they're not surprising. Everybody knows them, you know, avoidable hospitalizations, you know, barriers, difficulty getting appointments, like all the standard access measures. And they looked at us and they said, yes, you should report these. And they told us which ones they thought were more important. But they said, but you're missing our experience. It doesn't capture the challenges we have getting care. So in response to the community, we actually did a qualitative study of barriers to care of women from different disadvantaged groups in Ontario, immigrants, racial ethnic minorities, First Nations, disabled women, LGBTQ women, there was a huge literature out there, I learned, I worked with a PhD student and, and her supervisor who were qualitative researchers, learnt a lot about qualitative research. And we ended up with two papers, one on all the barriers people, you know, experience, and then we found one on agency that we don't think of that everything that people do, to deal with the system and how they overcome it. And some of those strategies are good, and others are not so good. But then when we wrote up our, our indicators, when we ran all of our data, it provided context to interpret what we were seeing. So I think that's really, really important. And also, you know, sort of checking back, you know, a qualitative thing. But even quantitative things, I was invited to present our results up in Muskoka, Ontario, which is where it's a cottage country, um, and, you know, to the local health integration network, and they did terrible on a lot of the measures, you know, they had more readmissions, more avoidable admissions, and I said, could this be right, you know, I thought of it is like, you know, affluent cottage country. And before publishing, I went up there, I showed them the results. I said, does this resonate with you? They said, Absolutely. You know, there's a lot of people here who are disadvantaged, we don't have, you know, good, coordinated care and we have holes in our health system. But so I do think it's important even if you're working with big data to go back and, you know, validate it with the community.

Victor Montori:

Yeah, that that's, that seems to be a lesson that needs to be learned and relearned and relearned and relearned. In our unit Arlene, we have three values, patient centeredness, integrity, and generosity. Any of these three strike you as closest to your heart.

Arlene Bierman:

That's a hard, that's like choosing between your children. But I think they're all really, really important. But I would pick patient centeredness.

Victor Montori:

Why would you say that?

Arlene Bierman:

Because I think if we have to have an effective health care system, we need one that is centered on patients who they are as people, their lives, what their needs are. And then I think you can't do patient centeredness without generosity and integrity. So maybe I'm cheating a little.

Victor Montori:

Yeah, I think you are. But I think you're right as well. It turns out that everyone we've asked that question ends up on some variation of the fact that it doesn't matter which one you choose, you need the other two anyway. Otherwise, you're dangerous. Tell us about, tell us about going to Canada? How, how did that come about? And what was what was different about that experience?

Arlene Bierman:

Oh, it was a wonderful experience. So um, I should say my mother is from Montreal. So I had a Canadian connection. I you know, I used to spend summers in Montreal with my uncle and my grandmother. So it wasn't, you know, a strange place. I think Toronto is a great city. And it to me was like a livable New York where I could live Midtown raise two kids and afford to live there. So, you know, it had a lot of draws. Um, yeah, I ended up going to the University of Toronto, and I actually had an endowed Research Chair. So I did a stint as an academic. And as a, you know, tenured full professor with an endowed chair, and I came back to AHRQ. So, you know, I, the choices I make are not the choices I think many other people would make.

Victor Montori:

Yeah, and but I think those are the choices animated by what you say is knowing what matters to you.

Arlene Bierman:

Mm hmm.

Victor Montori:

And where you might make the biggest difference. Coming back to coming back to government from a tenured professorship position, is almost like you're pathologically looking for discomfort.

Arlene Bierman:

Yeah, people thought I was crazy. But I love you know, I, you know, like I say, well, you, you know, what it's like, where we are I get to work with a lot of smart people. And I get to really, I think, make a difference in you know, in the research that's done across the country and improving care.

Victor Montori:

Absolutely. If you were to think back, I mean, sounds like you've had phenomenal collaborations with, with your colleagues in Queens in the clinic and with the communities there. Perhaps with the academics at Dartmouth, perhaps with Eisenberg and other colleagues at your first stint at AHRQ, your colleagues in Canada, you describe a big collaboration there. Now, your colleagues at AHRQ, if you were to think back, what has been your favorite collaboration, your best collaboration,

Arlene Bierman:

I'm going to cheat again, and give you two. Um, I think at, um, in Ontario, I was, you know, I mentioned before, I was a principal investigator of the power study that presented a health equity, we developed the health equity report for the province of Ontario. And I actually had 60 co-investigators who had expertise in the different, you know, reports that we did, but we also partnered with like, you know, the health system, the Ministry of Health, the local health integrated networks, you know, patient advocates, community organizations, public health, so and it was exciting bringing all these people together to have conversations. So it wasn't the data so much or the findings it was what is this telling us? And what does this mean for the health system? And, you know, when we started the project, I insisted on like, publishing the data at the regional level, and people were very nervous about it, they had just created the local health integration networks. And, you know, we don't know if you should do that, people are going to get upset. And the way we framed it is No, you just created them, they need to know their baseline, they need to know where they are, so they can do better. And we actually worked with the LHINs. We showed them their data before we published it. We gave them our SAS code, so they could run and track the indicators they wanted. And it worked out well, you know, so I think you have to kind of be creative, and how do you do these things in a way that's positive. So that was a great collaboration really broadly. I can say now at AHRQ. I'm just really excited about my e-care planning project. So we have funding from ASPE, which is the Assistant Secretary for Planning and Evaluation, which gets a portion of the PCOR trust fund. And and the purpose of this funding is to develop infrastructure to better do Patient Centered Outcomes Research. And Victor, you know, my passion for improving care with people for multiple chronic conditions. But one of the barriers is you don't know what everybody else is doing. And you lose a lot of what's happening to them if they go to different systems, different practices, so the real need for like an interoperable care plan that shares data across providers that's accessible to patients. And it's been a great collaboration we're partnered with NIDDK, we're developing it together. It's interesting, NIDDK started working on a care plan for people with chronic kidney disease. And I was working on one for multiple chronic conditions. And they quickly realized that, hey, these people with kidney disease have multiple other things. So they need, and you know, and they have a lot of more of the technical know how than I did. So it's a great, it's a great partnership. So we're doing that together. But we also have multiple federal partners involved, um, CMS, VA, Indian Health Service, ACL, I won't go on and on. So the federal team, you know, in terms of collaborating across the federal government, understanding how this could inform federal programs. But beyond that, we have technical expert panels who are helping us choose the data elements. But we've also partnered, HL7 has adopted us. So that hopefully, that these will be the standards to allow information to exchange interoperably. And what we were worried about is there's a lot of movements on care plans, and it'll end up like EHRs, where it's the Wild West, and they don't talk to each other. And they're all a little different. So we thought if we could get ahead of the game and develop the technical standards, people could use these and build on them and maybe we could have interoperable care plans one day. So, you know, that's a great collaboration.

Victor Montori:

Yeah Imean, so people, people listening to this, or watching this are gonna go Wait a minute, these are, these are federal agencies working together on this? What what world is that we're talking about? That is phenomenal. So, So Arlene, what does it take personally, to foster these collaborations? I suspect that's not the default. That it takes, it takes substantial commitment to the project and effort and I mean, what does it take?

Arlene Bierman:

I think it's willingness to listen, and to share, and other people are sharing with us too. So for example, um, you know, CMS had worked on developing a care plan for electronic, you know, long term care services and support. So they're willing to give us what they've done. So we could incorporate it in ours, so I think, making it a win win, understanding what people's problems are, understanding how you could develop this in a way, you know, I think that we're gonna have a better product, because we're going to know what our partners need in the, in the care plan to make it work.

Victor Montori:

Yeah. So you have a diversity of scientists, a diversity of collaborators, communities, are users involved as well?

Arlene Bierman:

Yes, Yes, they are. So we have, you know, a contract. Um, we have, users are involved in a couple of ways. We've included patients on our, you know, technical expert panels to talk about the measures and what they want to share about themselves. But we also have a contract with RTI and OHSU where we're doing focus groups and user testing, and also the developers are doing, using user centered design, to be able to develop this plan.

Victor Montori:

Fantastic. Um, we are getting questions now from some of the folks that are here. And I will select a few of those for us to consider as we go forward. But one of the things that is coming strongly here in our conversation is that government is a potentially great place for a young scientist to develop and so the person asking the question says, would you encourage young scientists today to pursue careers in government? Why yes, or why not?

Arlene Bierman:

So, absolutely, and, you know, um, maybe I planted that question because I'm recruiting. So if anybody wants to come work with us at AHRQ, we have a number of positions. So just reach out to me, but also, you know, what I want people to know is that whatever, at different phases of your life, you find the place where you can do the best with what you have and what your interests are. So that's what I tell people. It doesn't preclude going back into academia, you know, I was in practice, you know, I, you know, I went to government, I went to academia, I'm back in government. So I think, you know, and it enriches your experience. And I can tell people from, you know, working at AHRQ the first time, I learned a lot on being on the funding side. So I was really great grant writer, when I went back to academia, because I learned how grants were evaluated why things were funded or not. And so there's a lot of skills you could pick up also that you might not appreciate before.

Victor Montori:

It's interesting when I was considering a position in, in government, I was told by my advisors that once you go to government, you'll never come back to academia. So your clarification, I think, and your demonstration, and your own life stands in contradiction to that to that ill advice I got. And then somebody asked us the question: Are there ways to contribute, to contribute and engage in government work without moving to Washington?

Arlene Bierman:

Ah, well, yes, yes and no. So that's hard. I mean, I wish government was a little bit more flexible in terms of, you know, distance working, but we have different ways people come work with us um, we have fellows who come and spend some time and rotate with us, we have people, sometimes they're able to come on an IPA, which is, you know, part of their time spent with us. So I think there's, there's, and then there's participating, you know, we're very, AHRQ is very committed to engaging with stakeholders, and we have expert panels and other ways of kind of contributing your ideas. So there's ways to kind of get engaged with us without necessarily becoming a Fed.

Victor Montori:

Some of the most brilliant health services, researchers also work for the local and state governments. Right. That might be another opportunity is to engage with local and state government, local Medicaid agency, you know, these are all, there's other opportunities to work in government, there is not necessarily federal government, but it's a state government. I guess. That's another option.

Arlene Bierman:

And it's, you know, and I think the advice, I would also give is, you know, find out like, what question are you asking, and why, you know? And if you get an answer, it's like, the big so What question? And I think, you know, a lot of my research questions have been informed, I've had like a nascent idea, but really having it refined by, you know, consulting with the people who you hope to use your research. So that it is answering a question in a way that it helps them

Victor Montori:

Arlene this series of KERcasts, is in the context of our program of work of care that fits, you know, how do we help patients and clinicians form plans of care, that make emotional, intellectual, and practical sense to them and fit in their lives? And then how do we help patients work at home or in, at work or wherever they're, they're developing themselves, to, to make sure that that plan of care follows and particularly for a patient with chronic conditions follows them through life in ways that are perhaps minimally disruptive. Yesterday or last couple days AHRQ hosted a multi disciplinary international meeting on multiple chronic conditions. And I know you were an active participant and leader in that meeting, what does it mean to you today to make care of fit?

Arlene Bierman:

I think the care we have doesn't fit, right. And it particularly it doesn't fit for everybody, it doesn't fit for, especially people who have multiple chronic conditions, which is the norm.Jane Peterson was working with us on helping us organize this meeting said she told her husband who's you know, you know, an intensivist, and pulmonologist what she was working on, and he goes, but doesn't isn't that what everybody has? And I said, Yes, and that's the whole point. You know, that people get seen, different providers, different settings, get fragmented care, and we treat one disease at a time and not the person with the disease. And to me is care that fits is taking care of people, not their diseases, but they're people who happened to have different diseases in the context of their lives, and recognizing their values, preferences and goals in shaping a care plan.

Victor Montori:

Oftentimes, that is unavailable to clinicians either because of clinicians', lack of curiosity or skill to pick up the information that one gets from asking those questions and integrating them into, into care. But it sounds from your experience both in New York and Toronto that you had tremendous exposure to people from all over the world. How has that shaped your perspective about making care fit?

Arlene Bierman:

Well, I do think that we have to change, you know, we have to totally change care. And I think it's a cultural change in medicine, I think we have to change how we organize and deliver and pay for care. So I don't think it's easy. But I can tell you when, you know, most of my work was clinical, and I was sitting in the clinic in Queens, everybody who came into my office in an afternoon literally was from not only a different country, a different region of the world. And I would just sit back and ask, I said, like, um, you know, what did you do back home was my standard question. And I would get these amazing stories. And I was able to relate to my, you know, patients in a way of having a sense of, you know, heard incredible stories of, you know, people who had to leave, you know, were engineers and had to leave for political, you know, reasons, and we're now driving a cab in New York. And, you know, but I didn't see them as a cab driver and knowing who they were, and the disappointments and traumas, you know, people will experience torture, like just having a sense, who is this person in front of you? And what are the things that have impacted their lives and their health, I think makes you a better doctor.

Victor Montori:

Yeah, the we talked about taking into account their biology and their biography and in your biographical data that you were after, when you're asking that question, but any of those stories stick to your mind to this day?

Arlene Bierman:

Oh, um, yeah, no, there's, there's lots of them. It's hard to pick one, I think, you know, the one I mentioned, who was a cab driver, who was an engineer, and was asked to do some things that he thought he was working for, you know, a government, you know, input and was kind of being encouraged to get involved in some corruption and, and he, he would have no part of it. And he left the, because he refused he was being, you know, threatened and he left the country. And he was making a new life in the US.

Victor Montori:

Yeah, it is a, there is something and I don't want to put words in your mouth, but correct me if I'm wrong. But there's, there's something somewhat romantic about a, some of the things that you're describing, particularly back in your time in Queens in relation to having time to sit back and listen to stories, the opportunity to create a clinic, you know, that is open to everyone, regardless of ability to pay, that is able to do so with high degrees of quality and commitment to care. Why does it feel maybe this is me but maybe not, why does it feel that that is a world that is no longer with us?

Arlene Bierman:

No, we've lost a lot, but it wasn't. So, there were a lot of things that needed to change back then, you know, we still had the same pressure for volume. Um, you know, visits were often too short, especially for complex patients. But I think, you know, people don't realize if you know, your patients well, it's much more efficient, and you could do better care. And even if I got to know them over a series of visits over that's why continuity, I think is so important. Um, and I do think we have to move the, think about how do we redesign care and I can tell you, as you know, I you know, I directed the Department of ambulatory care at the hospital and we did, it was a big department we did about half a million visits a year. And then we started getting, I started getting volume visits from like, prenatal clinics, um, you know, well baby checks, and I said, I cannot see you know, my ninety year old only Italian speaking woman with five diseases in a wheelchair with an amputation in five minutes, I can't ask my doctors to do that. But I found as we were pressured to see more people faster, quality declined, because rather than understanding what the issue is, what's going on, working with people on you know, a plan of care that they could live with that would actually improve their health you're more pressured to make a referral, order a test so you haven't missed something. So I think that there's huge value in redesigning care so that it is human and and what do you, I remember I would do a clearance you know a surgical clearance for you know, so I'm a geriatrician as well, you know, a ninety year old who needed cataract surgery and had all these issues right. And I would not you know, I'd get an office visit for doing this clearance and then the you know, ophthalmologist got you know, thousands of dollars for taking out the cataract, and then afterwards any issue she had I was the one managing it right? So I, you know, we really do have to think about how we allocate resources within healthcare and why can't we allocate resources to do better primary care? I think it's worth the investment.

Victor Montori:

Yeah, there is a you know, there is a connection between continuity of care, unhurried conversations, care itself, and then care quality and improvement of outcomes. And Mark Linzer, who I know, you know, you know, demonstrated in Hennepin County how the slowing down the clinic had an effect of maybe creating a bit of a waiting list that, you know, went up first. But then as patients got their issues, addressed in the first time, correctly, they didn't go back to the back of the queue and continue to put pressure on the system, they went on to, to demand less health care. So there is that right?

Arlene Bierman:

Yeah, I'll give you two great examples of that. I remember one of my patients who was, you know, in her late 50s, she was overweight, she had, you know, type two diabetes and hypertension, she was depressed, you know, very common, and taking the time to ask her, you know, you know, explaining that, you know, maybe she could get off some of her, you know, medicines, if she lost a little weight and was more active, which we you know, sometimes see as futility, but working with her, what do you like to do, and it turned out, she liked to dance. And she took up ballroom dancing, she met people, so she was socially engaged, she lost a lot of weight, and she eventually came off all her meds. And to me, that's a success story of medicine. But that takes time and relationships. Another patient of mine was a retired truck driver. Again, he had had multiple heart attacks he had end stage COPD, he probably smoked in this truck. And he was one of these people who was readmitted every week or every month with, you know, decompensated heart failure, or, you know, you know, COPD exacerbation. And, you know, I, it took a while, but understanding who he was, his life, you know, so getting him on a good regimen, one that he could manage, you know, controlling his disease. But the biggest problem for him was he rented a room on the top floor of an old house that was very dusty, and moldy. And that was his, you know, no matter what he did, unless that changed, he was not going to be stabilized. Working with the social worker in the clinic, we had social workers, we have liason psychiatrists, and none of this is new, the social worker was able to get him into into subsidized housing. And he spent about a year and a half without having an admission. So you know, that's, so I think there's values to the system in getting it right and allowing people to have the time to understand why why are people in the state they are and what can you do to reverse it?

Victor Montori:

Yeah, I, as you know, I'm very committed to this notion of re, you know, shifting the aims of healthcare organizations that, that seem very committed to their operational efficiencies, the pursuit of value, and value to whom, at the end, and fortunately, it is a bit of a zero sum game and when the resources are tight, what you have described in terms of the churning of the patients, because of the shortened amount of time with them. It's a universal phenomenon. And it occurs in, in systems that enable, that allow for profit healthcare, but it also also occurs in systems that are publicly funded. And we're simply by decisions of austerity measures, the system is severely underfunded. And so the the final pathology of care if I may, is this churning of patients, which is cruel for patients because they're looking for care, and they're not getting much of a choice. But it's also pretty cruel for clinicians, because you don't, you don't get to care for them within that narrow of, in that such a narrow window.

Arlene Bierman:

Yeah, no. And I think, you know, I was fortunate to have like, the window of being able to practice when the pressures weren't as great. There certainly were pressures, but not as great as they are now. And see that transition, and feeling like it was actually harder and harder for me to practice in a way that I thought was effective and valuable. And maybe, who knows, if the system hadn't changed and was different I'd still be back in Queens, you know, happily, you know, practicing medicine.

Victor Montori:

Yeah, um, we have a couple more questions that relate to career and, and one of them is, has to do with as you as you pursue a research that is participatory, how do you, how do you find, what is your, so there's a lot of PCORI, for instance, has been very active at the moment with trying to engage stakeholders and patients in research. People struggle with this, you know, who are these people that get to participate as stakeholders? Who are these people that have the time and disposition to actually take part in research as patient partners? Do we have equity issues? What are your thoughts about the state of patient engagement or involvement in research?

Arlene Bierman:

Well, first of all, I just want to say, you know, absolutely, how critical that is, um, and in order to, you know, really inform your questions inform what you're asking, I think we do need, you know, engagement of people or patients in that research. That being said, Yes, it has to be real, you have to think about who it is, where they're coming from, why they're involved. And I think, you know, that's the, I think that's the advantage of being engaged in your community, because then you could really, you know, identify people who are, who are users who you're serving who can actually, you know, so I do think people need to be cautious of, you know, not just, it's not like a checkbox in an EHR, you happen to have a patient, but what is the relationship? What are they representing? And what can they bring to the project? And diversity absolutely, to make sure that, you know, different patients voices are captured?

Victor Montori:

Do you see a time where research funding agencies will fund patient led research, research that where the PI is a patient, not an academic?

Arlene Bierman:

I don't know. I really don't know. That's a good, that's a great thought. I do think it's a time for us to really think, you know, not only what what research questions, you know, I always thought like, researches what matters in researche is not only what questions get asked, but who gets to ask them. So, you know, whether that's a partnership with patients and whether it's patient led, but I do I think we need to start rethinking in a lot of ways, like how do we do research? How do we keep it rigorous? And, you know, make sure that we're doing good science, but really open it up to a lot more different perspectives?

Victor Montori:

Yeah, it's, it's, you know, and who gets to judge whether the research is worth funding, I have the same problem with a review committees, where again, PCORI has been able to expand the review committees to include patient representatives and other stakeholders, but has had to deal with issues of training them and so forth. And, and, and again, issues of representativeness versus advocacy. Many of the folks initially that walked through the doors or PCORI were advocates, patient advocates, and they had an agenda, right that which was not to judge quality of research and pertinents of research, but it was the agenda of their disease or their condition. It was, it was complicated, but it sounds I mean, if your career is any, any any way of looking at this, that you're, you're you're rarely slowed down by challenge. What is inspiring you today? What is next for Arlene Bierman?

Arlene Bierman:

So I, you know, well, you attended our multiple chronic conditions summit, I would like, if I have a chance to implement that agenda that comes out of that meeting, I would be in heaven. I think that would be exciting. That would be great. But I do think about like, what comes next for me because I've made so many different jumps. You know, having worked in Canada, I'm very interested in cross national comparisons and what we could learn internationally in healthcare delivery. Because the other thing I learned in Canada was that very different systems at the point of care, the problems are all the same, you know, so I would, I would like to maybe do some work on global health related to aging. Um, but on the other hand, I can see getting very micro again, and going back to a safety net system and really working on population health. So one, a very local or very global, I'm not sure but for now, I hope I get a chance to stay at AHRQ and do our multiple chronic conditions agenda.

Victor Montori:

Do you, do you think medicine today is a career that young people should consider? Seriously?

Arlene Bierman:

Yes, yes, absolutely. I think you know, there's lots of challenges, but it is so rich. Um, you know, first of all, I mean, I still enjoy you know, medicine and understanding the body and understanding diseases, but you could just take so many different paths with it. Um, and I think the way you know, hopefully will be I, you know, like we we talk at AHRQ about not only the scientific cure, which, 21st century cure, but the science of care. I think that's developing. And I think there's a huge opportunity to really figure out how do we organize and pay for care in a way that makes a difference in people's lives and, and as well in population health. And I think, you know, um, there's also you might not know this about me, but in addition to my fellowship at Dartmouth, I actually did a fellowship in community and preventive medicine. And I've been living in two worlds all my life. And I think there's a great, a great opportunity to bring together public health and clinical medicine. So I think the opportunities are enormous. So I would, it's challenging, it's not easy. But if people know why they're doing it, and what they're doing it for, I would really encourage people and I and I love mentoring younger people, you know, going through medical school, or residency,

Victor Montori:

Arlene we are coming to the end of our conversation, but it just occurred to me that, you know, we have a generation of future physicians, nurses, therapists, pharmacists, future researchers, research leaders, people who are going to lead research agencies, funding agencies, who have as part of their biography, having lived through the COVID pandemic, and and through this time in general, what have you learned so far from, from what you've seen with COVID

Arlene Bierman:

Oh, what a tragedy. Um, but I do think it's an opportunity, I think all the mistakes that were made, you know, I just feel for all the people who've been affected, all the family, everybody who's lost loved ones. I mean, the magnitude, I don't think we can even get our hands around the magnitude of the, you know, the tragedy of COVID. But I do think at the same time, as all the people who've stepped up, you know, the practices who went to telehealth, you know, overnight. And I think, you know, just looking at, at what COVID is, you know, brought in front of our face in terms of how the system doesn't work, the inequities in our system, I think there's more attention being placed on the need to focus on public health. But, uh, hopefully, we'll see also the primary care system could be so critical, you know, not only and, you know, taking care of people with COVID or not, is seriously ill screening test, you know, testing, but also keeping people well, and mitigating risk, who are living with diseases and how critical that is, and reaching out to communities at high risk for COVID. So I hope that we take this as an opportunity to really learn a lot of lessons and say, you know, how can we change our healthcare system to be better?

Victor Montori:

Phenomenal, Arlene. I've learned a number of things from COVID, as well. But one of the things that I think I've learned that is important is that scientists working within the government have made an enormous contribution to the health of people at a time that's very difficult and in a in a world that has, has and remains quite confused about the role of science. The fact that we have at AHRQ someone like you is, is an incredible, an incredible privilege. And I want to express my gratitude for your service.

Arlene Bierman:

Oh, thank you. Thank you.

Victor Montori:

I think it's absolutely essential. Thanks Arlene for participating in our, in our, in our KERcast. This, this brings our program to an end and I would like to invite everyone to join us for the next KERcast and to join me in expressing our gratitude to Arlene. Please, stay well, be careful, and see you next time.