Improving Healthcare for Everyone - A Conversation with Stephen Schwab

“When I think about a project, I think about what can we learn that’s going to help healthcare as a whole. I’m interested in how do we improve healthcare for everyone.”

Interfacing with healthcare is something that everyone must do? But beyond considering your provider’s background or credentials, have you ever considered how your relationship might impact the care you receive.

This episode's guest is Stephen Schwab, an Army veteran who served three tours in Iraq. An assistant professor in management in the Carlos Alvarez College of Business, his work is focused on the role that interpersonal relationships play in maximizing performance. He examines this issue in the context of healthcare — the largest industry in the U.S. economy.

Stay connected with the UT San Antonio Carlos Alvarez College of Business to learn more about how we are empowering the next generation of business thinkers. Follow us on social media or visit us online at business.utsa.edu

Transcript

Stephen Schwab, PhD 0:00

So, when I think about a project, I think about what we can learn that's going to help healthcare as a whole. I'm interested in how do we improve healthcare for everyone.

Jonathon Halbesleben, PhD 0:08

Interfacing with healthcare is something that everyone must do. But beyond considering your provider's background or credentials, have you ever considered how your relationship might impact the care you will receive? Welcome to Inside Alvarez Business, a podcast dedicated to bringing you the stories behind the research. I'm your host, Jonathon Halbesleben, Dean of the Carlos Alvarez College of Business at the University of Texas at San Antonio. This season we're focused on the business of healthcare. We're sharing the stories of our faculty, the real-world impact of their research, and what led them to study these important topics. Our guest today is Steven Schwab, an Army veteran who served three tours in Iraq. An assistant professor of management here in the Alvarez College of Business. His work is focused on the role that interpersonal relationships play in maximizing performance. He examines this issue in the context of healthcare, the largest industry in the U.S. economy. Enjoy this episode of Inside Alvarez Business. Steve, welcome to Inside Alvarez Business. We're delighted to have you and I'm really excited to hear the stories behind your research.

Schwab 1:09

Thanks for having me, Jonathon. Excited to talk about it.

Halbesleben 1:11

Yeah. So before we really get into your research, one of the things I like to ask people, in part because I'm just curious about it, is how you decided to get into an academic career at all. You know, it's not something most people grow up thinking they want to do. And so I'm sort of curious, what was your path to becoming a faculty member here in the Alvarez College of Business?

Schwab 1:34

A lot of luck.

Halbesleben 1:35

Okay.

Schwab 1:35

It was, you know, I never even thought about this path, honestly. As a kid,

Halbesleben 1:41

Mmm-hmm.

Schwab 1:41

I was split between wanting to go into politics and wanting to be a teacher.

Halbesleben 1:45

Oh, okay.

Schwab 1:46

Yeah. So my my mom was a school librarian.

Halbesleben 1:48

Mmm-hmm.

Schwab 1:48

I had two aunts and an uncle that were teachers

Halbesleben 1:52

Mmm-hmm.

Schwab 1:52

For grade school, high school through high school. And when I was getting ready to go to college, I decided I was gonna study political science. I was very interested in politics. And then I joined ROTC and I went in the army and I had this whole career, and I kind of put all that behind me. As I was thinking about getting out after, I guess it was my second or third tour in Iraq. I was thinking about getting out, and I started, oh, well, maybe I'll do troops to teachers, this

Halbesleben 2:16

Oh, okay. Yeah.

Schwab 2:16

Which is this pathway to get former soldiers to teach in the classroom.

Halbesleben 2:19

Yeah.

Schwab 2:20

And then I looked at what teachers make and said, you know, we had our first kid on the way, and said, Yeah, I just don't think this is gonna be the right path for me. And so then I ended up going to this whole healthcare finance for the military and staying in. And what I was part of that is I got selected to go to get my master's. And I was at this program that it's joint between the military and Baylor University and taking stats and traditional business classes. I ended up tutoring a pretty large portion of my cohort.

Halbesleben 2:49

Okay.

Schwab 2:50

And I found that I really did still enjoy it. And as I was going back and thinking about what I want to do, I realized the parts of the military that I always really enjoyed were the mentorship. It was the, you know, teaching in a in a you know, it was more of a one-on-one, but it's the same sort of idea of what we do. Um, meanwhile, sort of flash forward, and I get this job as the first the a budget officer for medical research within the military, and then later on as the CFO of a research institute. And I started really getting interested in research and thinking, this is really cool stuff. We're pushing the, you know, what we call the production possibilities frontier, the, you know, the ability to create new stuff and do more with what we have forward. And I was like, this is really cool. I think I want to do it. Around that time, the military put out a call and they were looking for someone to go get a PhD and to teach in this program I had gone through between the military and Baylor.

Halbesleben 3:43

Oh, okay. So you've been kind of coming back home almost.

Schwab 3:45

Yeah, exactly. Right. And so I started thinking about it, and I called a couple of my former professors and said, "Hey, what do you think about this? I really like teaching." And they said, "That's great, but like, do you really like research? Because this is what professors do. Understand that teaching's great and that's a part of it, but you better like research." And one of my former professors was was kind enough to put me on a project and let me get a little bit of my hands dirty with it. And I said, you know what? I actually the other part I really liked was arguing with people, having a point in crucial. [laughs] And so I sort of said, you know what, I think this is right for me. Let's apply. And so I applied the army, they selected me, and then I applied for grad school and I got in, and sort of the rest is history. And, you know, I just I've never regretted that path. I've just enjoyed it both in the army and now out of the army doing this kind of work.

Halbesleben 4:35

Yeah, no, that's so awesome. It was, it's interesting to hear kind of how the things came together. It's also interesting to hear you sell yourself like extremely short [laughter]. The reason I'm saying that, I mean, it's not like people just say, you know, I think I'll get a PhD and I'll go to Wharton to get the PhD. So clearly you had some oomph behind your abilities as well. So congratulations.

Schwab 4:59

Thank you. Yeah, I mean I'll say I have a philosophy of never self-rejecting. And so Wharton had a cool program, and I was like, well, I mean, all they can do is tell me no, I'm gonna apply. And yeah, got in.

Halbesleben 5:09

Yeah, well, I'm glad you did, because otherwise you wouldn't be here. So I'm glad that that worked out. And then it sounds like for a while you actually went and then worked in that program, the the joint program with Baylor.

Schwab 5:20

That's right. I taught there for three years.

Halbesleben 5:22

Okay, cool.

Schwab 5:22

And that was the you know, research was sort of on the side from the military standpoint. They need you to teach.

Halbesleben 5:27

Right, right.

Schwab 5:27

And so that was really mostly a teaching position, not as much research, although I did as much as I could, knowing that eventually this is what I wanted to do with my life. But I did get to teach, and that was a phenomenal experience, both from just I got to teach a lot of different things.

Halbesleben 5:42

Yeah.

Schwab 5:42

And part of having a military program is they can't plan out the professors the same way you do at a traditional university. And so I got handed things to teach. Basically, if it had quantitative anywhere in it, whether it was finance or accounting or statistics, I taught it - economics. And so I got a lot of experience teaching, and it was a healthcare focus because it was this joint master of healthcare administration and master of business administration. And it was, you know, I got to learn a lot from teaching things that I probably wouldn't have on a traditional career path.

Halbesleben 6:16

Yeah, no, that's really cool. I admire your kind of interesting path. So that's great. So before we also get into some of the details on your your research, I mean it seems like it might be a little obvious just given your your background, kind of the the path you took toward the end of your career in the army. But I'm I'm curious, you know, what was it about healthcare that you thought that's the the area that I want to focus on?

Schwab 6:42

Sure. So I should start with in college. I was need to fill out a course in my schedule. And I had a roommate who was an EMT and said, "Oh, you should go take this EMT class."

Halbesleben 6:51

Oh, interesting.

Schwab 6:52

Yeah. And so it was worth four credits. It filled up my schedule and said, okay, that's cool. I'll go do this. And I just fell in love with it. I just loved sort of the adrenaline of emergency medical, right? You're making decisions and all these things that go along with it. And I got a chance to do some rotations through the emergency room and hang out on an ambulance. And so I actually at that time had one change my major to emergency medicine management. Unfortunately, the army, they had to produce so many officers each year, and I was in an ROTC scholarship, and they said, no, it's gonna take you an extra year. We're not willing to do that.

Halbesleben 7:25

You gotta keep going.

Schwab 7:26

You gotta keep going. And so, but when I went in the army, they branched me Medical Service Corps, which is the sort of medical administrators for the military, ended up doing a bunch of medical work. And so as I moved in my career, that was just sort of the industry I knew. And then sort of, you know, as things come full circle, when I was a kid, my dad was very sick. So my dad suffered from agent orange poisoning from Vietnam, along with very severe PTSD. He got, he had to have major surgery when I was in fifth grade. By the time I was in eighth grade, he could no longer work.

Halbesleben 7:58

Oh wow.

Schwab 7:59

And so just seeing sort of - thinking about that pathway. And I hadn't thought about this when I went to college, right? It wasn't, it wasn't like it was four front in my brain, but as I started getting more into the medical field, it sort of came back to me about how important this was. And then dealing with people and being in Iraq and dealing with all the interactions of individuals who, you know, couldn't even get motrin if they had a headache or an aspirin to help with blood flow. It really sort of, it clearly would clue all these things into my head about how important healthcare is.

Halbesleben 8:30

Yeah.

Schwab 8:31

And then, you know, one more just thing on this topic is my dad ended up suffering from major depression from his inability to work because of his healthcare.

Halbesleben 8:39

Oh, yeah.

Schwab 8:40

And so I just, it really sort of sparked in my mind how much healthcare just impacts every other aspect of your life. And even me, right? My sort of human capital that came from my parents and the experiences I had because my dad was suffering and all the, you know, all the parts of my life that that affected.

Halbesleben 8:59

Yeah. I can really see how that would give you some motivation to try to figure out how we can make this better as a system. So well that that's really cool. If you don't mind, I want to talk about a few of your kind of more specific projects and just as I mentioned, we're really interested in is just kind of hear the story behind the paper. You know, if we all I was gonna say we all could read the papers. I don't know if we all could necessarily read the papers, but, because they're pretty sophisticated [laughter]. But really what to me, what's most interesting is kind of how you got to the problem and that type of thing. So, for example, one of your recent papers was published in the the journal Science, which is you know one of the most prestigious journals, and found some really interesting patterns with regard to power differences of patients and physicians, and some pretty startling findings regarding patients with higher power versus patients with lower power. Can you talk a little bit about kind of what you found there?

Schwab 9:54

Sure. So the the paper itself finds that if you have more power, power is this whole, if you talk to sociologists, has all these different elements of the definition, but we really think about just people who have more status in society, whether that's because of wealth or that's because of position. What we we wanted to know is okay, does that status actually impact the care that you got?

Halbesleben 10:16

Yeah.

Schwab 10:16

And use, you know, we looked in emergency rooms where patients are somewhat randomly assigned to different physicians, and we found that when patients had more status, they got more care, right? So more care doesn't always mean better care.

Halbesleben 10:30

Yeah.

Schwab 10:30

So certainly more expensive care. And then we see some things that say, you know what, not only is it more expensive, but there's at least suggestive evidence that it's actually better care. And so, for instance, we see that they get readmitted to the hospital within 30 days less often if they are a higher status patient, and they get more care when they're actually in the emergency room. So, and we do this in the military where we have ranks and we can look at the patient's rank as a marker of their status compared to the physician's rank as a marker of sort of their level of power. And this, you know, largely came from personal experience. Again, I mentioned my father was sick. I can't remember how many doctors just either wouldn't believe him or blew him off when he was getting sick. And, you know, my dad was he, you know, he was a fine member of society, but we weren't wealthy. He didn't have some, you know, great job. He wasn't, you know, sort of on the higher echelons of this sort of societal status, the way we think about it.

Halbesleben 11:26

Yeah.

Schwab 11:27

And I just observe this. And the other thing I'll point on this is we've talked to people, this is sort of like the worst held secret. Like most doctors we've talked to have been like, yeah, I don't mean to do that, but I acknowledge that this comes into comes into play.

Halbesleben 11:40

Yeah, yeah. No, I can and I can see how it would, especially. So in this particular study, the way you kind of thought about power, conceptualized power was in terms of rank. And so, you know, you had situations where the the patient was of higher rank than the physician. And so I could see that you know that there's sort of this relative rank with across patients, but then that dynamic with the physician, it's not like that necessarily the physician's rank was held constant in all of this, I'm assuming.

Schwab 12:09

Yeah, so that's the that's sort of the key from a like statistical analysis point, is what we didn't want to pull up is just okay, if you're a more experienced physician, you do things better differently. Or as you get older, you tend to get more power because you're you gain wealth as you get older. We didn't want to be just pulling in sort of the impact of being older and wealthier. So everything we look at holds those ranks steady and then just looks at the difference between the rank of the physician and the provider. Or I'm sorry, the physician and the patient.

Halbesleben 12:38

Okay. Okay. I now I understand. So that did you did keep that consistent.

Schwab 12:42

We did, we did. Now there are there's variation in there, but we end up controlling for that. So the key thing is, is there a difference here? The other thing we look at is we looked at patients before and after a promotion. So let's say they were more junior in general.

Halbesleben 12:58

Yeah.

Schwab 12:59

But we they happen to go to the ER, say six months before they're promoted versus six months after. So the age doesn't really change a lot in here.

Halbesleben 13:06

Yeah.

Schwab 13:06

And so the sort of things that you might worry about as people get older aren't there. And what we found is they get about 1% more expensive care if they come in after they're promoted versus just before they're promoted.

Halbesleben 13:19

Oh, that's interesting.

Schwab 13:19

And 1% might sound like not sound like a lot, but these things add up. And what I say is like most physicians are doing the best they can.

Halbesleben 13:27

Yeah.

Schwab 13:27

Right. It's not like you would expect that they're like, oh, this is high rank. Let me give all my effort. Oh, that low rank person, forget them.

Halbesleben 13:33

Right, right.

Schwab 13:34

It's sort of on the margin that you think these things come into play. And how much do I listen to you? How much do I believe what you're telling me?

Halbesleben 13:41

Mmm-hmm.

Schwab 13:41

How well do we have that conversation?

Halbesleben 13:43

Yeah. I think you know, it's interesting. I think about my own career, and, you know, my primary care physician, for example, knows that I'm the dean of the Alvarez College of Business. Like it's in my note [laugh]. And, you know, I as you describe this, I kind of wonder the extent to which maybe I'm getting a little bit better care than if he just didn't know that, that I had that title, or you know, if it what it was like when I was you know younger in that that type of thing. So I don't necessarily have any evidence or I can't really see it. And I mean, I have a great doctor right now. So if anything, I would have to rule out the the confounding factor of I have an amazing doctor right now, and I've not always had amazing doctors.

Schwab 14:22

Yeah.

Halbesleben 14:22

But I can kind of see how this would play out, outside of the military setting as well.

Schwab 14:28

Absolutely. So we - that was one of the big parts of getting this into Science was this is a generalizable, right? And there's enough qualitative and suggestive evidence that this was occurring that we just found a setting where we could really clearly statistically identify it.

Halbesleben 14:43

Yeah.

Schwab 14:44

What I'll say is we don't think it's like every doctor giving, say, 1% more care.

Halbesleben 14:48

Yeah.

Schwab 14:48

It's 1% of doctors that give, you know, twice as much care and on average is out. So it's hard to say, you know, if you didn't tell that doctor you're the dean, how does it go? We would never say that like that that's the sort of core. It's that people, people are humans, doctors are humans, doctors are subject to the same incentives of everybody else. And there's gonna be people who are, oh, okay, right? Like, oh, you're the dean. I'm gonna listen more.

Halbesleben 15:14

Yeah.

Schwab 15:15

Versus you know, somebody else.

Halbesleben 15:17

Yeah. That's really cool. What changes do you think need to happen in the healthcare system to address this? If any. I mean, maybe you maybe we're not talking about big enough effects that you worry too much about it, or is it maybe just as simple as awareness on the part of the doctors that this is a bias.

Schwab 15:31

So that's what we talk about in the paper is that we think a lot of this is just awareness. So we don't take a stand on whether we think this is explicit versus implicit biases, but we do sort of, you know, at least personally, I think that most doctors I've ever met are doing the best they can.

Halbesleben 15:46

Yeah. Yeah.

Schwab 15:47

And so awareness, and I've had a number of doctors say, "oh yeah, you know, I didn't realize I was doing it at the time, but now thinking back, you're right, I actually do this." The other thing is there's this whole idea of shared decision -making in healthcare, that the doctor and the patient should be discussing it.

Halbesleben 16:01

Yeah.

Schwab 16:01

And so we think that there's a way to really like focus in on training for shared decision -making that gives more voice to the patient.

Halbesleben 16:09

Yeah.

Schwab 16:10

When I say more care, a lot of that just came from spending more time with the patient.

Halbesleben 16:14

Right. Right.

Schwab 16:14

And so you can imagine that there's things that we can do that would, you know, give everyone sort of more attention. The challenge is the more attention you give to any one person, it's coming from potentially attention coming from someone else.

Halbesleben 16:28

Yeah.

Schwab 16:29

And we actually show that in the paper that there's these spillovers effect. If you, are a low status patient seen in the same shift as a high status patient, you actually get worse care. And so part of this is an access issue of how do you expand the system enough to allow everybody to get that kind of attention.

Halbesleben 16:46

Yeah. That's really cool. Switching gears just a little bit, you another one of your recent publications examine what happens when a physician leaves a care team. And can you talk a little bit about what you found with that study?

Schwab 17:01

Sure.

Halbesleben 17:01

That one I found, I have to admit, that one I found particularly interesting.

Schwab 17:04

Yeah, this is one of my favorite pieces of research. So this is based on my dissertation.

Halbesleben 17:08

Okay.

Schwab 17:08

So this I thought about for many years.

Halbesleben 17:11

Yes, sounds like it.

Schwab 17:12

And this, so I'll get start with the sort of outcome, right? We find that when a patient is forced to change primary care physicians, and we do this in a way that the primary care physician left the care team, as you mentioned. And so the the patient is still going to the same office, they're just seeing somebody else in that same office. So they're not moving, they're not changing insurers, all these other things that you could think might confound the results.

Halbesleben 17:35

Yeah.

Schwab 17:36

We find that on average, they are referred to a specialist more often rather than be treated by that primary care physician. And it ends up increasing costs by about 6% per patient per than per year. And that's again largely due to the fact that the physician just seems to have less information about that patient versus when you have an ongoing relationship. An example that I came across, this didn't make it into the paper, and I don't even know who to attribute it to. I just sort of read this somewhere. But it was a doctor's experience talking about how they had a patient come in, and the patient they were working on getting him to quit smoking, right? And he'd been doing smoke and cessation, he quit smoking, and he comes in and he's a mess and he's back to smoking. And just making sort of conversation, the doctor asked him, "H ey, how's your dog doing?" This guy was very into his dog, right? Had a, and turns out the dog had died.

Halbesleben 18:32

Okay.

Schwab 18:33

Right. And so rather than prescribing him medication, he said, I'm prescribing you, go get another dog. And that sort of switched, right? This like depression he was going through, this, you know, getting back on, you know, on the non-smoking or the smoking cessation plan was really he just needed something. Well, that's not something that goes in your notes, right? When you're writing the notes, it's not like patient has a great relationship with his dog. But by knowing each other, this created, right? And so this is this idea of why when someone leaves, you lose this information. And now the next physician that's seeing him doesn't know all these, all this history, or all these idiosyncratic pieces of information. And so when they're on the margin of, "Hey, do I need to refer this guy? Is this something I can treat?" They defer more to let me refer this person.

Halbesleben 19:22

Oh, interesting. Okay.

Schwab 19:23

I should add one more point. So on average, it was about a 6% increase in costs. That is widely dispar ate, there's a wide disparity in there, right? So diabetics, we see like a 30% increase in costs.

Halbesleben 19:35

Oh, okay.

Schwab 19:35

Your average 19-year-old, healthy adult, there's no it doesn't make a difference.

Halbesleben 19:40

Yeah, yeah. Oh, I could see that because I mean I would imagine there's some conditions that could be mostly treated by the primary care physician, but once you send it to a specialist, the cost would go away.

Schwab 19:52

That's exactly it. And once you see a specialist, you tend to continue to see a specialist.

Halbesleben 19:55

Yeah. Right. Yeah. That makes sense too.

Schwab 19:58

Yeah. And so yeah, it was it's just really, I think, interesting impact of turnover. That's widely not captured in sort of our normal models of okay, here's the accounting cost of somebody leaving and I got to replace them.

Halbesleben 20:12

Yeah. What was kind of cool to me was the the way turnover happened in this study. And I we're gonna come back to this issue of some of the opportunities you've had because of your ability to study the military healthcare system. But could you talk a little bit about that? Because I think that that's it. This wasn't just like doctors saying, ah, I'm moving on. Yeah. This is this was interesting to me.

Schwab 20:33

This is what made this study, I think, special compared to other studies that have thought about the same thing, is that we had this change that was neither decided by the patient or the physician. So when a physician decides to retire, which is a lot of this literature was based on, they're making a decision to retire. And it could be, you know, could be they're burned out, it could be a hundred other things, could be they don't like their patients, right? Like, yeah, who knows? But we use military data where physicians work in a standard system, just like the civilian system here in the United States, when they're not needed for operational deployments, but the military comes in and says, "Hey, Dr. X, we need you in Iraq, you're leaving."

Halbesleben 21:10

Y eah.

Schwab 21:11

And so there was this sort of exogenous change in that somebody from this much higher level is coming in and saying you have to leave. And this allowed us to really look at the statistically.

Halbesleben 21:23

Yeah. How much time do people usually get when they find that out?

Schwab 21:26

You know, it depends. It could be a month, it could be a year. And so we did a bunch of work around here to make sure that there was no anticipatory effects.

Halbesleben 21:34

Yeah, because I mean I'm thinking about when you're talking about people who retire. I mean,

Schwab 21:38

Yeah.

Halbesleben 21:38

You most people don't just like wake up one day like, ah, I'm done. Yeah.

Schwab 21:42

No, it's the same thing. Most I would say on average, people have three to six months' notice.

Halbesleben 21:46

Oh, okay. So there is maybe a little bit of time where they could try to increase the amount of information that gets passed on. But it's still difficult to do.

Schwab 21:53

It's it is, and we we did a bunch of work around trying to see if that was happening, and we couldn't find anything. Showing that that was actually happening.

Halbesleben 22:01

Yeah. Well, I guess especially in primary care, where I mean, maybe you're only seeing your patient once or twice a year. So the thought, like, "Hey, I gotta go back and see who I saw two months ago and make sure their notes are updated."

Schwab 22:14

We did get some like qualitative rights just from discussions on background that said, hey, for my re like my most, you know, my most sick patients, we do maybe a more of a warm handoff.

Halbesleben 22:26

Yeah.

Schwab 22:27

But even still, that information just it still just doesn't really transfer. Like there's a limited amount of how much you can get out there.

Halbesleben 22:34

Do you think... I've been so fascinated by these these AI tools that listen to the conversations and then then create create notes based on them? And just am fascinated by how well they do. My doctor shows me the note every time because I find it so fascinating. I'm like, man, that we kind of agree, neither of us could summarize the visit better than the AI thing just did [laugher]. So do you think maybe that's part of the solution to this? I mean, like maybe the dog thing gets in, gets in there because the doctor doesn't think to put it in the note, but it the AI piece might have caught it.

Schwab 23:06

So I think that's a difficult question to answer. I think it could, but it could also cause other problems. So I'm also, and I think we were talking about this off-air before about you know, I'm doing some work on this ambient listening technology and its impact on the doctor-patient relationship. It can certainly gather more than would typically, because the cost of writing something down, you you've basically eliminated. The challenge is now do you get too much? Because somebody has to actually read the note.

Halbesleben 23:32

Oh, that's a good point.

Schwab 23:33

Yeah, physicians have a limited time to read the notes that are out there. And so they're gonna focus on the key information that's in that note when they see the patient the next time. And so if you start writing a book, it's it's gonna take too much attention and they're gonna end up ignoring it.

Halbesleben 23:47

Yeah. Uh you know, that's so fascinating when you say it, because I hadn't thought about that. But uh, this seems like the type of thing where novel information also could be problematic in that you know, you pick up on the dog thing and you miss like some other really piece important piece of information. So it you'd almost have to train the AI to kind of stage the information of like, okay, here's the really critical stuff. And by the way, this might be important too, but maybe not, you know. So, but yeah, I could see how you pick up on the novel stuff at the expense of the routine.

Schwab 24:22

And and the other thing is like, so some of the stuff is just could you write it? Some of the stuff is just relationship, right? So we talk a lot in about in the paper about trust. Now, trust is I have no way of measuring trust.

Halbesleben 24:34

Yeah.

Schwab 24:34

Others might, but I don't. Certainly not the type of work I do. Could we measure that? But we certainly believe that that's probably part of this relationship too, and the communication that occurs between the doctor and the physician.

Halbesleben 24:47

Yeah. Well, as an IO psychologist, I'm not sure we have a great grasp on how to measure trust in other a lot of other settings either. So I can kind of confirm that that's a problematic thing to measure in in many cases. So you know, you've looked at this relationship between the physician and the patient and some other work as well, including a paper where you looked at the tri-care system in the military. Why is that such an important area to understand?

Schwab 25:15

Let me just make sure I understand the question. Why is the doctor-patient?

Halbesleben 25:18

Yeah.

Schwab 25:18

Okay. So the reason that I think the doctor-patient relationship is maybe the most important part of understanding is this is where care happens. Right. At the end of the day, this is what I would call as an economist a joint production function. Right. It's both the sort of the knowledge and the skill of the physician and the patient's willingness to communicate and then willingness to sort of follow what the physician has instructed. And then also there's this whole, again, joint decision making of what's best for that patient, which at the end of the day, it's it's the patient's decision, right? Patient, if physician says you need surgery and the patient doesn't want it, they don't get right. That's yeah, at the end of the day.

Halbesleben 25:59

They tie them down and just start.

Schwab 26:01

Yeah, not necessarily the other direction. But I think this relationship is really the core of our healthcare system. It's the working together of somebody who has one piece of information and somebody who has another piece of information. So in economics, we talk about information asymmetry. The fact that the doctor knows a lot about medicine, but they don't know as much about their patient as that patient will. And there is no way they could possibly ever know as much about that patient as that patient does. And so that working together is where I think we're gonna see improvement in our healthcare system.

Halbesleben 26:36

So looking at the study that you had done with the TRICARE system, that one was kind of interesting because you found some sort of different patterns with military patients versus civilian patients that were kind of within that same system. Can you talk just a little bit about what you found?

Schwab 26:51

Yeah, so what we actually looked at um, if you're talking about the paper, I think this is the health affairs paper. Yes. Okay, so it was actually looking at military patients. Um, well, it was actually their family members. So we were all looking at civilians, but some were seen in the military health system, and some were paid for by the military health system, but seen in the civilian world.

Halbesleben 27:08

Oh, okay.

Schwab 27:09

Now I understand better. Yeah. And then we get different patterns of the way uh these occur. So our sort of theory going into this was the military moves doctors and patients around. Um, it's just part of being in the military as you move around for lots of reasons that are probably beyond the scope of this conversation. And we felt like because of that, you should get less variation in the military because of all the things that that come up and what we know about variation in care. So I should probably give a little background for listeners about what variation in care means. And in in healthcare, we worry about what we call unwarranted variation. So it's you go see one doctor, you get one decision, you see a different doctor, and you would get a different decision. For a patient with the exact same symptoms, same diagnoses, right? All the information is the same. Exactly. And we know this occurs, right? So there's been work on this for over a hundred years about why some doctors are sort of more likely to perform surgery and others are more likely to go more conservative management. The reason that this is important is if if you have one doctor that wants to do the expensive, but they could be treating it the same outcomes with somebody doing the less expensive, well, that's a waste of money. And we know our healthcare system is absurdly expensive. And so we we honestly, you know, again, people have been working on this for a hundred years. How do we get everybody to sort of do the lower cost version that gets just as good outcomes? And that's an important part, right? The outcomes are the same in both of these situations. Well, we thought, well, in the military, because you're moving people around, you have less of this, oh, I've been working with this guy and we do all things the same, and there's a bunch of literature about peer effects on this. And we thought, okay, well, if you're moving everybody around, you shouldn't have a lot of this sort of unwarranted variation. It should be much more standardized. Where in civilian care, we know that there's all this variation that occurs. But what we found is that variation occurs in both systems. Okay. Um, that despite this moving people around, it hasn't limited the variation. Now, where the variation is, is it more about specialist visits versus more primary care? Those are a little bit different between the systems. Um, the military tends to perform surgeries less often. So we saw a much lower C-section rate versus um the civilian care system. But overall, we really didn't see much difference between the military system and the civilian system, which we found very surprising.

Halbesleben 29:33

Yeah, yeah. I and I'm guessing the military system, you mentioned like the less specialty care. I'm guessing in part because there's more control over the the financing of the whole system as well.

Schwab 29:46

Yeah, yeah. Actually, so this is interesting. Actually, we found the military they were more likely to refer.

Halbesleben 29:50

Oh, really? Okay, I think I'm I've misunderstood that.

Schwab 29:52

Yeah, yeah, yeah. No, in the military, they're more likely to refer to a specialist, and we think probably it has to do with incentives. So if I'm a military primary care doctor and I think somebody might need a specialist, I just put in the order and and do away with it. If I'm a primary care doctor in the civilian world and I get paid more if that person comes back to me, I may be less likely to refer them to a specialist. So we see a little bit more primary care in that civilian system and a little bit more specialty care in the military system. Oh, that's interesting. Okay. That that is interesting.

Halbesleben 30:20

Yeah, that's not not what I would have thought.

Schwab 30:23

No, and again, it was this went contrary to what we would have thought, but the results were very robust to trying different things in a way that we were convinced that this was this is what this is what the research showed. Yeah. And even though it didn't sort of meet what we thought it was gonna show, we felt was important to still write it and publish it.

Halbesleben 30:40

Yeah. Very good. Another recent study. We're kind of bouncing from study to study to here, but but I I am gonna actually bring this together in the next thing I'm gonna ask you about. But um, you found something really interesting and perhaps really troubling uh regarding opioid use uh resulting from variability and how likely emergency room physicians were likely to prescribe opioids. And it kind of goes back to the the first study we talked about where you don't necessarily get to pick your doctor when you go to the emergency room. And so it's an interesting context to study this. Um, I'll be honest with you, that this study was kind of scary to me, you know, the the results of it. Can you can you talk a little bit about that one and what you found?

Schwab 31:18

So this starts with the same idea of this variation in care that some physicians do things differently than other physicians. Um, and part of that, and there's a whole research on like why this is something that has to do with training, something has to do with experience. But what we found is that some physicians are just more likely to prescribe an opioid than others. And about a quarter of ER visits in the military, and this is pretty similar in other systems, end up getting an opioid, right? Somebody sprains their ankle or breaks their alarm or whatever.

Halbesleben 31:43

Yeah, but if you're if you're going to the emergency room, it's probably bad enough. You need you need a little bit uh more of that kind of treatment.

Schwab 31:50

Exactly, right? You need some sort of pain treatment.

Halbesleben 31:51

Yeah.

Schwab 31:52

But we found that there's this wide variation in prescribing what we call propensity, right? So across all the patients that a physician sees, some physicians order lots of opioids and some don't, because maybe they're more scared of it or they're just more aware of the negative impacts for whatever reasons. Uh, some physicians prescribe a lot and some don't. And there was, um there have been two previous papers that I was aware of that looked at this and they both sort of found something similar. So one was uh a New England journal piece and another was an economics piece, but they both sort of came to the same conclusion that getting an opioid drastically increases the probability that somebody gets addicted to opioids. Yeah. Um, which now, again, you're talking pretty low baseline levels, but massive increases on those low, low levels.

Halbesleben 32:45

Yeah.

Schwab 32:46

We wanted to know now, okay. Well, you've told me that these people are more likely to do things like keep keep going on opioids or doctor shop, meaning try to find a doctor to give it to you. Um what's the actual impact of this? Because these papers really couldn't tell us much about the impact of those opioids. Yeah. And we really want to understand how does this affect people's job performance? And what we found is that a patient who saw a provider that was more likely to prescribe opioids was both more likely to get an opioid, sort of the first part of this, um, but also they were more likely to get in trouble at work, they're more likely to be kicked out of the military, they were more, you know, less likely to get promoted, all these sort of negative impacts on the labor market. Um, and to me, this was a really important finding to understand, okay, not only from just an opioid perspective of which is already really important with everything that's gone on in the country with the opioid epidemic, but also understanding, okay, this variation in care and and how physicians act impacts every aspect, going back to the same thing with my father, right? Yeah, yeah, and all these different impacts that we really understand, like who you see and what they do impacts a life well beyond just, you know, the cost of healthcare.

Halbesleben 34:07

Well, and that's what was so terrifying to me, to be honest with you. Yeah. Uh because of the because of the setting. And it's, you know, you you've got an emergency, you go to the emergency room and you get whoever's there. Um, that that that could have that kind of set you down a path. It does.

Schwab 34:21

That was really interesting. One of the things I thought was really important about this is understanding, right, from a manager's perspective. Okay, if I've got a uh if I have an employee who was a high performer and all of a sudden they're not performing well, how do I now think about it? Do we think about figuring out what the core issue is? Because these issues are treatable, versus in the military, we're kicking people out when potentially these are issues that we could have dealt with at the time simply by, you know, intervening in the fact that now we have uh, you know, uh an opioid problem. Um, and again, it could be other, it doesn't have to be opioids, but it could be any sort of like healthcare, right? You're recovering from surgery, you're in pain. There's lots of reasons why you might think somebody doesn't perform as well. And now we're giving sort of managers, hopefully, the sort of knowledge to say, okay, something's wrong with this person's life. How do how do we intervene in a way that gets them back to being a high performer versus just punishing them for being low performer?

Halbesleben 35:19

Yeah. You know, I think that's such an important message of the study, too. Um, kind of thinking about you're you're making that point, but you're also tracking it back to how that's how they got there. Um, and I mean, when it effectively is something completely out of their control, completely, you know, it does sort of change the perspective a little bit on how to how you manage that person and how you you the approach you take if they're they're struggling. And so um, in some ways, I I like that the as terrifying as the study is, I do I do like that it, you know, it kind of makes that connection to say, look, this person might be struggling, it might be they're struggling due to addiction. That addiction might have been because of effectively a completely random occurrence in their life. Um, and so I I think that that to me that kind of changes the perspective a little bit from the manager's uh point of view.

Schwab 36:09

I agree. I mean, I think one of the things I've I've come to realize through my time in the military is my time as an academic, and you know, ask me how I got in, you know, I said luck, right? There's just a lot of randomness in life. Um, and that's not to take away from the fact that people work hard and I I believe I worked hard to get where I am, but there's also this amount of randomness that, you know, part of what I want to do is say, okay, well, can we invest in people and help sort of people help themselves and and overcome sort of these bad luck events?

Halbesleben 36:39

Yeah. This seems like such a tricky issue to address as well. Cause I mean, uh obviously uh you you mentioned that people uh who are prescribed an opioid are more likely to get addicted to an opioid. Well, of course, because if you never took an opioid, you'd just logically become addicted, right? Um, but the solution there is not necessarily to say, okay, no more. Like, you know, and so that it makes it makes that really tricky in figuring out what the standard of care is and how much of an opioid you need to prescribe and at what points. That that that is really difficult to deal with, especially thinking about the patient physician relationship there, where you don't have the history necessarily in an emergency setting. That's right.

Schwab 37:20

That's right. And I think this is an important because there's been there's certainly been people policy-wise that are sort of opioids are bad. And opioids are not good or bad. Opioids are a drug, they are an addictive drug, they are also a very effective painkiller.

Halbesleben 37:34

Right, right.

Schwab 37:34

And so, how do we, how do we balance this? And then knowing, you know, just like if any medical operation, there's a risk, how do you mitigate the risk? Yeah. And and that is part of, you know, and that's sort of a later study that we're gonna do is this sort of transitions. Okay, you saw in the ED, now how do you go back to your primary care? And how do we in you know integrate mental health care into that in a way that, okay, you have this this higher risk, but we can mitigate that risk.

Halbesleben 38:00

Yeah. Yeah. So all of these studies kind of bring us to uh a question I want to ask you about. So it seems that working within the US military health system has given you some really unique access to data. And that's allowed you to answer some really interesting questions and and generate some really new insights. What makes that system so unique that that allows for this?

Schwab 38:23

Yeah, that's a great question. Um, so I would say the the number one thing that makes that system unique is sort of the the top-down military mentality, right? So we're forcing people to move, we're telling them what they can, we're changing policies in a way that allows the research to be done in a way um so that you don't have to worry as much about selection. Yeah. Um, major issue in in research, as you know, is selection. And so what we're able to do is sort of say all else equal. Everybody has the same insurance plan.

Halbesleben 38:53

Yeah.

Schwab 38:53

Because you, if you try to look at something like the doctor patient relationship, well, a lot of that work, well, this person was forced to shift off their insurance. Well, now you've got so many other things going on in their life that it's really hard to say all else equal.

Halbesleben 39:06

Yeah.

Schwab 39:06

And as a microeconomist, that's what I'm interested in. I'm interested in all else equal, what is the impact of this on that, A on B? And the military provides a really good way to do that. Um, now it has other challenges of dealing with military data. Sometimes there's a lot of movement and you have to figure out, okay, now how am I going to isolate this?

Halbesleben 39:26

Yeah.

Schwab 39:26

The patients are generally not as sick as you might see in something like Medicare.

Halbesleben 39:31

Makes sense.

Schwab 39:32

And so the ability to see an effect is sometimes um harder statistically because I can't like people always ask me, well, did you look at mortality? It's like, I'm dealing with, you know, average age of 23. Right. We're not picking up an effect on mortality. Right. Yeah.

Halbesleben 39:47

That's really cool. What's been interesting to me too is that in all the studies, even though you're studying a really unique system, it's not hard to see how it would apply to other systems. You know, clearly there's elements of it that are that are unique, but the things that have been isolated, they happen in the other systems. They just are isolated a little bit different way in the military system, which I think is really useful.

Schwab 40:12

That's always been so when I think about a project, I think about what we can learn that's going to help healthcare as a whole. There are people who are interested in military healthcare and they do research to help the military healthcare system. And I certainly write white papers that I send to the military on the findings on some of this stuff. But I'm interested in how do we improve healthcare for everyone. And the military for me is a great setting to be able to isolate things and then offer to the broader population about how, okay, how can we think about turnover or the doctor-patient relationship or variation in care in a way that's going to help sort of the nation as a whole or people as a whole.

Halbesleben 40:49

Yeah. So you kind of mentioned this a little bit earlier, but, I'm curious what's up next for you? What could what's the next big study that you're working on?

Schwab 40:58

Yeah, so I've got a I've got a couple things. So I have this bad habit of taking on way too many projects at once. But the the paper that's closest to going out right now that I was supposed to have out last week, but you can blame me. Is on skill depreciation. So again, using military data and looking at doctors that deploy, we have doctors that come back and they haven't performed their jobs primarily for say six months.

Halbesleben 41:27

Oh, yeah.

Schwab 41:28

And this happens to civilians. So job breaks are fairly ubiquitous. People get burned out, they decide they're gonna take some time off, they have maternity or paternity leave, or, as I've talked to doctors, right, they get injured sometimes and they can see office visits, but they can't do, say, surgeries because they broke their foot.

Halbesleben 41:48

Yeah.

Halbesleben 41:49

And so we have a lot of times that people go, say, six months, nine months without doing their job. But almost all of the work on this looks at either very small breaks or looks at very mechanical, right? Like how long does it take to put together an airplane? That's sort of one of the dominant studies in this. And so we want to say, okay, well, what happens in much more um, you know, intellectual work uh when somebody has to take time off? And and we in this study, we look at two different types of physicians. So we look at surgeons, which is a very mechanical skill, and we look at OBGYNs and and delivering babies, where it's much more judgment call. Should this be a C-section, should this be a vaginal delivery? Okay.

Schwab 42:30

And we look at both of these types of providers when they've been deployed for months, average deployments, six to seven months without, and when they're deployed, they're not doing these jobs. They're doing yeah, they're not delivering babies. And even the surgeons are really they're just making sure somebody doesn't die and gets them to a better hospital.

Halbesleben 42:49

Right, right.

Schwab 42:50

Yeah. And that's a key piece of it, right? That they're and we show this in the paper that they're not doing typical work. The surgeons take a couple months. When you first come back, their re-admission rates are like 60% higher than they were before they left. So this is all looking at that physician and how they performed before versus when they come back. So it's, and on average, you have this massive increase in re-admission rates for surgeons, but it it's pretty short-lived. Within a couple months, they're sort of back to baseline, right? Again, and it sort of stands a reason. Mechanical skills, like it's like riding a bike, right? You get back on, you haven't done it for a while, you maybe you're a little wobbly, but yeah. You know what you're doing.

Halbesleben 43:30

It comes back to you pretty quick.

Schwab 43:31

Yeah. The judgment call, so the OBs take much, much longer. So in the order of six to seven months before their C-section rates return back to normal.

Halbesleben 43:41

Wow.

Schwab 43:41

And part of this is when a woman is in labor, they go through, they rank babies on this sort of one to three scale of like how much distress they're in. And the idea is you want to keep babies at sort of the minimal level of distress. You have this like number two, where you're sort of eh, you don't know which way it could go, and then three is bad, right? And so when the baby hits that two, there's a decision to be made about how long do you wait to see if they go back to one, or because you want to get in and do that C-section before they get to three.

Halbesleben 44:14

Yeah, you don't want to risk them getting it.

Schwab 44:16

Exactly. And so, you know, there that's a huge judgment call. And you might think that confidence and experience plays a major role. And what we find is that, you know, the longer it's been since you've done this, the less sort of I say confidence, we can't measure confidence. We can just tell you that the c-section rates come elevated, but we think it's really about sort of confidence in their own judgment based on their experience. And it takes a while to rebuild that sort of confidence, which is very different than I think than the mechanical skill.

Halbesleben 44:45

Yeah. Wow, that is a I can see why that would be something you're passionate about. I mean, that that's really fascinating. A fascinating area to get into that would have sort of widespread application you know outside of the healthcare settings also. I mean,

Schwab 45:01

Absolutely.

Halbesleben 45:02

My gap was much longer than and I can't blame a deployment, but I mean, like it had been a while since I taught in last semester I taught. And it's just like all the things you just don't think about.

Schwab 45:10

Exactly.

Halbesleben 45:11

And then all of a sudden you're like, oh, that's right, I gotta I gotta turn in my grades.

Schwab 45:14

Yeah, yeah, no, exactly, right? And we don't think this is a healthcare, like again, we use a healthcare setting.

Halbesleben 45:19

Right.

Schwab 45:19

And we think the healthcare applications are very important, right? But same thing with, you know, the patient -physicians work. Like, we think like how people interact with each other and the fact that there's idiosyncratic knowledge that gets passed is a is important for any organization to understand that turnover is gonna have an impact way beyond what you can like your accounting costs.

Halbesleben 45:38

Yeah, yeah.

Schwab 45:39

People are just gonna be less productive because they don't know, you know, who to ask when they have a question.

Halbesleben 45:45

Yep.

Schwab 45:45

Yeah. And so here we think that what we think, or I should I should add in, so we find that when surgeons do sort of less intense surgeries, so we call minor surgeries, before they do these big intensive surgeries that we we mostly focus on, it actually reduces how long it takes to get them back to baseline.

Halbesleben 46:06

Okay.

Schwab 46:07

And it reduces the impact on those major surgeries and on the increase in their re-admission rates. And so we think that there's some like important managerial. So if you have somebody who's teaching who hasn't taught in a while, there's things you can do to help them get back into it quicker than if you just say, hey, here's your classroom.

Halbesleben 46:24

You're right, right. Very good. Well, hey, having talked to you in other settings, you know, offline, I know you are an incredibly busy guy. So, but I'm also curious, but one of the things we're trying to highlight is that you know, the people that work here are humans also. So outside of work here in the Carlos Alvarez College of Business, what types of things interest you?

Schwab 46:45

Okay, so I should mention I have a wife and three kids.

Halbesleben 46:48

Okay.

Schwab 46:49

My kids are eight, eleven and fourteen. And so I coach my 11 and 8-year-old. My eight-year-old plays baseball, my 11-year-old plays softball. I used to coach her in basketball as well, but she's since decided that she just wants to focus on softball for now.

Halbesleben 47:02

Oh, okay, very good.

Schwab 47:03

And she's in band, she plays clarinet, so she's doing other things, but I coach them. I should ask, is it you want me to talk about the political stuff or just

Halbesleben 47:12

If you want to.

Schwab 47:12

Okay. So, as you know, I'm also running for political office. So I'm running to represent my area in the Texas legislature, and so that's taking certainly keeps me busy. And then, you know, just you know, family and friends, and I'm president of my homeowner association trying to

Halbesleben 47:31

Oh my goodness. That might be the more difficult political task.

Schwab 47:35

Oh [laughter] you know, I the reason I got involved because you have some people who are so anal about things that I just wanted to like relax it.

Halbesleben 47:44

Yeah.

Schwab 47:44

Yeah. And so I got involved, and then and then COVID hit and people had a lot of issues, and so then you get sort of involved trying to help people and you stay.

Halbesleben 47:52

Very good, very good. Well, it sounds like with your kids too. I don't I sometimes joke I'm a part-time Uber driver. Yeah. Just a direct connection of the kids. They're the only ones I drive for, but just getting people to where they need to be can be it is quite a task.

Schwab 48:06

And we're also three so three UTSA sports season ticket holders. So...

Halbesleben 48:12

I know you've told me football and then you you've told me that I'm gonna not get remembered what are the other two?

Schwab 48:17

Baseball and women's basketball.

Halbesleben 48:18

Very good, very good. Well, you picked but you picked some good ones. I mean, baseball and basketball. Baseball, yeah. Women's basketball seasons, yeah. They've had some really great seasons. So that's terrific. Yeah. Well, good. Hey, before we wrap up, one thing I want to be sure to do is to thank you, not just for all the work you're doing, but also your service to the country. Oh and we've we focused a lot on the research and the work you know work you're doing in the healthcare setting, but I know your service went much deeper, included service during the Iraq War, including three deployments to Iraq. So you know, thank you. So and in some ways, even your commitment to service is showing in your run for office as well. And so thank you for your sacrifice on behalf of all of us. Well, it is certainly appreciated. So thank you.

Schwab 49:03

Appreciate you saying that. So

Halbesleben 49:04

Well, Steve, it's been such a joy talking with you. I've really appreciated this opportunity. And we all interface with the healthcare system. So I'm glad to know that we have amazing researchers like you that are trying to tackle some of these really interesting issues and difficult problems that we see with the healthcare system. So thank you for being here today. And more importantly, thanks for the great work that you're doing to improve all of our lives.

Schwab 49:25

Thank you. Thank you, Jonathan. Enjoyed it.

Halbesleben 49:30

Thank you for listening to the Inside Alvarez Business Podcast. Special thanks to our producer, Brittney Johnson, and for the support of Wendy Frost and Melissa Lackey to help make this podcast possible. Stay connected with the Carlos Alvarez College of Business at the University of Texas in San Antonio to learn more about how we are empowering the next generation of business thinkers and conducting groundbreaking research to ensure their success. Follow us on social media or visit us online at business.utsa.edu. Until next time, I'm Jonathan Halbesleben. Thank you for listening.