"Urgent Calls from Distant Places:" an interview with author Marc-David Munk, MD

Many thanks to Marc-David Munk, MD, MPH, author of "Urgent Calls from Distant Places: An Emergency Doctor's Notes about Life and Death on the Frontiers of East Africa," for joining me on this episode of The Art of Medicine with Dr. Andrew Wilner! He's an unusual doctor who wrote an amazing book!

While in college, Dr. Munk began his medical career as an emergency medical technician. His interest in saving lives evolved into an academic career in emergency medicine. Overwhelmed by an imperfect healthcare system that rewarded productivity at the expense of quality, Dr. Munk volunteered for the AMREF Flying Doctors program in East Africa in 2008. He returned for another year in 2012. 

Years later, Dr. Munk delved into his journal to write a thoughtful documentary of his time with the Flying Doctors. The stories include life-saving adventures and his response to the widespread health inequities of East Africa. He recounts these experiences in astonishing detail in his book, "Urgent Calls from Distant Places."

These exotic volunteer experiences spurred Dr. Munk's further education and practice. He obtained an advanced degree in healthcare management and worked with healthcare models that respect the physician-patient relationship.

Currently, Dr. Munk works as a palliative care physician at an academic center in Boston.

To learn more about Dr. Munk, please read his book and visit his website: https://www.mdmunk.com

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Transcript

“Urgent Calls from Distant Places”

An interview with Marc-David Munk, MD

Introduction

Welcome to the Art of Medicine, the program that explores the arts, business, and clinical aspects of the practice of medicine. I'm your host, Dr. Andrew Wilner. Today, I'm pleased to welcome Dr. Marc-David Munk. Dr. Munk is the author of “Urgent Calls from Distant Places,” the story of his work with AMREF, a flying doctor air ambulance service in East Africa. 

On my 30-minute commute to the hospital, I listened to the audio book-beautifully narrated by Dr. Munk. As much as Urgent Calls is an incredible adventure story, and I'm going to ask Dr. Munk to share some of his experiences, it's also a story of self-discovery and purpose. I've done some medical mission work myself in the Philippines, and many of Marc's observations and reflections resonated with me. I'm looking forward to a very meaningful discussion in just a few moments. But first, a word from our sponsor, LocumStory.com.

LocumStory.com is a free, unbiased educational resource about locum tenens. It's not an agency. LocumStory answers your questions on their website, podcasts, webinars, videos, and they even have a Locum's 101 crash course.

Learn about locums and get insights from real-life physicians, PAs, and NPs at LocumStory.com. And now to my guest. Welcome, Dr. Marc-David Munk. 

Marc-David Munk, MD

Great. Thank you, Dr. Wilner, for having me. 

Andrew Wilner, MD

Marc, you know, I'm really excited because when I read a book, or in your case, I listen to your book, to actually have an opportunity to speak to the author, you know, it's very rare.

It's like, gee, what was he thinking? Why did he write that instead of, you know, this? And here he is, like, well, you know, in the video flesh.

So thank you for joining me because I do have a lot of questions. And it is a fascinating story. But as I said in the intro, it's a lot more than just an adventure story, right?

I think it's a story of self-discovery and purpose. I mean, it's much, much more than just, gee, I went to Africa, you know, with the flying doctors and I had a great time, and it's really cool over there. I mean, it was nothing like that.

It was written by somebody who, and your quotes at the beginning of each chapter, I didn't know all of them. Some of them I did, but they're very literary. These are quotes from somebody who went to college and paid attention, you know, and read a lot of books.

It's a very serious book, but not at all dull. And I know how it ended, but there's also more after the end, which is what you're doing now. So we're going to get to that.

I'm very excited about that. So first, your medical background.

[Marc-David Munk, MD]

Sure. So thank you very much for the warm introduction. And I'm actually delighted I have an enthusiastic reader.

It's hard when you put a book together to imagine anybody wants to read it. And so at least I have a few, you being one of them, Andrew. So thank you.

Medical background. Listen, I went to medical school a little bit late. I never intended to become a doctor, actually.

I, at one point, thought I was going to be a journalist.

[Andrew Wilner, MD]

Well, that shows in your book. That shows in your book. Absolutely.

[Marc-David Munk, MD]

I had dreams in the early days of being a journalist, but I was actually quite fortunate. I went to college in upstate New York, and it was in a small town of a few thousand people. And they had a volunteer fire service and a volunteer ambulance, as many rural towns do.

And I was interested in what it was about, and I joined them. And I went to community college at night and trained to become a medic. And that was my introduction to medicine.

And it turned out for me to be a great fit, but it wasn't anything I thought I was going to do. So I appreciate you commenting on my literary background. In fact, I was a terrible student in college and barely got through college and had to, after I left, go back and remediate by taking a bunch of science classes that would qualify me for medical school.

And miraculously, there was a school in Philadelphia that was foolish enough to say yes. And so I was accepted to medical school and made it through and became a doctor, which wasn't anything I would have anticipated when I was younger. But I've loved it since.

I went into emergency medicine, trained at the University of Pittsburgh, practiced academic emergency medicine for about 10 years, and then did some pivots, which I'm sure we'll talk about later in the podcast.

[Andrew Wilner, MD]

I like that term, you know, pivots. People talk about changes. But I think most changes for people with a background like yours and mine, they're really pivots.

It's the same thing, but it's sort of a different focus. It's not a change. So there was a day, so you practiced ER medicine for 10 years.

By the way, I was an ER doc when I was trying to find my direction for one year in the midst of my – and that's when I discovered neurology, which was interesting, and that sort of pushed me in. So you never know what you're going to find. But there was one day when you were doing ER medicine, you said, okay, I've got to do something different.

All right. What happened that day?

[Marc-David Munk, MD]

You know, I had reached a point where I had finished medical school and I had finished my residency program, and I was finally working as an attending. That was a moment where most of us wake up and say to ourselves, we've made it. I've done it.

I've made it. I've achieved what I set out to achieve. Isn't life great?

Except I was looking around the ER thinking to myself, life isn't really that great. I mean, this is a very, very stressed environment, and we are under the thumb of a really dysfunctional system, which resulted in ER crowding top to bottom, and really the inability for me to deliver the type of care that I really thought I should be delivering. So you just didn't have time to do the procedures which we were qualified to do but didn't have the time to do.

And it was, to my mind, more of a question of triaging as quickly as you could to keep up with the inevitable surge of people coming through the front door. And I said, is this really what all those years' training were spent to accomplish? I just can't believe that this is what medicine is supposed to be.

And so, for me, that set off a period of real soul-searching where I was trying to understand what I originally thought was so attractive about medicine and which I wasn't experiencing in my day-to-day life. And that's really what kicked off actually the visit to Flying Doctors.

[Andrew Wilner, MD]

Right. So I was reading about Flying Doctors. It's quite an established institution in East Africa.

It was 70-plus years, right, formed by three volunteer surgeons. We're going to fly out and save people.

[Marc-David Munk, MD]

Yeah.

[Andrew Wilner, MD]

And they're still doing that.

[Marc-David Munk, MD]

They are. So it was, you know, the Flying Doctors is an extraordinary organization founded really by a group of grassroots idealistic physicians. There were two Englishmen and an American, a fellow called Tom Reese who was a plastic surgeon actually with an interesting background.

But the three of them really were passionate about delivering care. It was hard to get around Africa in those days, 60, 70 years ago. So a couple of them were pilots and they got into their Cessnas and they started flying into these bush strips in the savannah and setting up clinics or going to small hospitals and running the surgical clinic that was there.

And their stories are pretty extraordinary, right? They're dealing with gorings from wild animals and terrible car accidents and all your standard surgical emergencies as well. And over time, the organization just became more formalized.

But it was really a grassroots effort in the early days. It was doctors coming together and volunteering and raising some money. Tom Reese was an interesting fellow because he was a Church of Latter-day Saints fellow from Utah who ended up migrating to New York City.

And he became for a number of years really society's top plastic surgeon in New York City. Like he was the guy you went to when you needed a nose job and you were a starlet. But he would take a certain number of months every year to go to Kenya and practice this type of medicine.

And he loved it and was there really for most of his life. He only died not long ago, I mean a couple, maybe 20 years ago. But I visited him shortly after my first trip back from Africa and found him just such a warm and extraordinary fellow.

He'd retired to Santa Fe. So that was Flying Doctors. And as you say, it's really grown into something different.

It was volunteers and small Cessnas. It's now a highly professional organization, part of a larger organization called AMREF, which does more than this medical evacuation business. They also do clinical outreach clinics.

They do training. They have a medical university where they train technicians and other healthcare workers in Nairobi. So it's become a massive million-dollar organization, still not-for-profit, and still running the Flying Doctor service.

So if you are a tourist on safari in Kenya and something bad happens, more likely than not, the only people who will be able to get you out are Flying Doctors because they know the place backwards. You don't bring in an outside air ambulance. You bring in AMREF, and they run East Africa and deliver extraordinary care.

[Andrew Wilner, MD]

That's good to know. I do have that evacuation insurance for my diving adventures in remote locations. Hopefully I won't meet up with your colleagues.

But you're sitting there one day, okay, I'm going to do something different. How does East Africa show up on your radar?

[Marc-David Munk, MD]

It was a bit of an accident. I came home from a shift one day, and as you do, it was like middle of the night because your shifts end pretty late. I was trying to figure out what was next.

I remembered vaguely that we had a friend of the family who at one point volunteered, he was a pilot, and had gone to Africa and had spent some time working with these people. So I just looked them up online and came across their website, and there happened to be information. I emailed the medical director there, and I said, are you guys looking for a doctor, an emergency medicine doctor?

Miraculously, they wrote back and said, yeah, not only are we looking for a doctor, but we're looking for one in a couple of months. Can you be here soon? It was one of those snap decisions where I called up my boss in the ER, and I said, I'm out of here, and I'm going to go to Africa.

I applied for my Kenyan medical license, and before I knew it, I was on a flight to Nairobi to fly for these guys. That was the first of two trips. The first one was 2008, and the second one was in 2012.

For both of those trips, I kept a pretty detailed blog because I was in those days keeping a blog for friends and family at home, which is kind of what you did, right? You remember those MySpace or whatever those were called? So I kept a blog for friends, and as a consequence, I was very good about documenting the various cases that we went on and the nuances of traveling through East Africa.

So when I was finally ready to write the book, a decade later, I had all the material with which to base these stories on.

[Andrew Wilner, MD]

That must have been just an amazing experience to say, okay, I'm going to write the book, and we'll talk about how you decided to do that. But you open up your notebook, and it must have just brought you right back to the heat and the sweat and a little dizzy from going down the runway. Because I was very impressed reading the book, the detail of each encounter.

And then you did something that a lot of people don't do. And when I read these sort of books where people have had adventures during the war, what you did, which is exceptional, is that you put it into context. So not only did you fly to some godforsaken city, you gave the whole history of why it was a godforsaken city, that the Belgians had been there for a while, and then it changed hands, and they were exploited by these people and exploited by that people, and this had given the opportunity for this particular tribe to take over, which was at odds with another tribe.

I mean, you did like a little mini PhD thesis on all of these locations and how they came to be. I thought that was really fascinating. Obviously, not something you just picked up casually.

I mean, you just got home at night and looked this stuff up. It's like, how did this place get—am I right?

[Marc-David Munk, MD]

Oh, you're 100% right. I think that in the absence of context, in the absence of knowing the history of things, you might as well go to Disney and do an exciting ride, right? Because that is just sort of cheap experience porn.

You go there, and you don't know what it's about, and you don't know why it looks the way it does, and you don't know the reason people behave the way they do. And you're just sort of—it's a very cheap way, I think, to just absorb a couple thrills. And to me, that's what a tourist does, but not what a traveler does.

What a traveler does is goes to a place, tries to deeply understand the people there, where they came from, why they behave the way they do, why the place looks the way it does, and you try to integrate yourself into the broader context. In the absence of that, it's just a thrill. So I appreciate you calling that out, because I really tried hard.

And as I said in the introduction, I also probably didn't do a good enough job, because I'm not a historian, and I think it's hard, even as a traveler, to really deeply understand what makes a place tick. I mean, you're in there for a short amount of time, especially if it's a flying doctor, right? You fly in, you're on a landing strip for a couple hours.

Maybe you take a Jeep ride to a very rural hospital and pick somebody up. And so it's a very superficial glimpse, but I think it's— in the absence of understanding what you're seeing, you might as well not be there.

[Andrew Wilner, MD]

Well, it's always been—you know, there was a movie about that many, many years ago. It was like, if it's Tuesday, it must be Paris or something. And the idea was, you're literally a tourist.

And frankly, I always found when I was in college and I first started going abroad, it's like, I just wanted to go to one place and stay there for a week. You know, everybody else, I want to see this. It's like, no, I don't want to do that.

I just want to go to one place and kind of feel it, you know, and see what that place is like. So I'm very sympathetic to what you did. There's one story.

Unfortunately, I listened to your book while driving, so I couldn't take notes about what—you know, I usually underline stuff, and I can go find them later. But there was a particular story you had— well, one theme that runs through the book, and I don't know if it connects to our current day or not. We'll see.

But one theme is that in Africa, there is a level of corruption that Westerners are not used to. I mean, there's corruption everywhere, there's no question about it, but it seemed extreme. And you talk about green, you know, the paperwork and stamping, but there's green paper, right?

The green papers. And there was a section where you flew into somewhere and you expected a lot of this green paper, but there was a man who showed up who was, I think, a bishop. He was a religious figure.

And as soon as he stepped on the tarmac, everything changed. He got respect, and the usual kind of blatant pickpocketing stopped. And you researched why that was.

It was very striking to you, I think, at the time, because it was so unexpected, but it said a lot about the history. Could you just comment on that story?

[Marc-David Munk, MD]

Yeah. The line was you wanted the green forms and the blue forms, or you wanted the red forms and the blue forms, but we also need the green forms as well, right? So that was the line.

Yeah, you know, corruption was endemic, as it is in most developing countries, frankly. And it's small-time corruption for the most part, although I think probably at a bigger level, there's a lot of big-time corruption as well. But that's just generally how things get done.

And unfortunately, it's the way that people eat. They're not paid well, and this is a multimillion-dollar jet that falls from the sky, and they see an opportunity to make a couple bucks, and that's how they feed their families. And I don't have a great solution for it.

I know that AMREF worked very hard not to pay those bribes, and I think for the most part, we're successful in not doing so, because, of course, once you start, you're sort of on the hook. And I think people recognize that there was enough of a humanitarian mission here that they were going to let this stuff slide. But Goma in particular, in the DRC, was one of those places that was notoriously corrupt and where all organizations struggled, primarily because it had been wracked in war for so many years.

Even still today, actually, if you check the newspapers, Goma is in the midst of a terrible crisis yet again. It's the same actors, for the most part, tearing the country apart. It's very difficult.

But the story was quite interesting, because DRC was formerly a Belgian colony, and the Belgians were not particularly good colonial powers. There was a lot of brutality. Many of the institutions that they created just didn't work at all, whether it was schools or hospitals.

And so these were colonies that were really suffering in terrible ways by particularly bad colonial powers. Not that any of them were great, but the Belgians were reputed to be particularly bad. And so for years, the only people who provided services or infrastructure was the Catholic Church.

And people over the years grew to trust the Church, and the Church opened the schools and opened the hospitals. And so it was very interesting when we flew in. Our patient at the time was a priest who was quite sick and needed to be evacuated from Goma and taken to Nairobi, where the only cath lab in East Africa is.

And we were expecting just sort of a plague of locusts to descend on the aircraft and beg for money. And some of these people sat on the wing and wouldn't get off until you paid the bribes, and we were just expecting this whole thing to happen. And so the priest shows up in the back of a van, and there's a nun there, and people are very worried, and the guy just looks terrible, and we're stabilizing him.

And there's a sudden silence that descends, and we look over, and there's this figure walking across the tarmac dressed in spotless vestments, perfect white gown, the purple outfit, the robes, the whole thing. And he walks over, and the place just snaps to attention as he shows up, and all eyes are on him. And he gives a couple commands to the workers, and they go scurrying off, and instantaneously the priest is on board, and the nun is sitting there with her bag, which contains the money for the hospital, the cash that she has to bring to Nairobi.

And we stabilize the fellow, and the bishop of Goma basically claps his hands, and people jump to attention, and the doors are closed, and we're out of there, and we've never had such a painless trip to Goma. But in the absence of understanding why the Catholic Church is so important there, you wouldn't really understand the nuances of what had just happened, right? And so love that story.

[Andrew Wilner, MD]

It's kind of an inspirational story, too, because it shows that even in the midst of what is usually chaos, order is possible. Order is possible. You just need kind of the right combination.

So I think that story is just fascinating for a lot of reasons. Okay, so I'm interested in this particular part. You gave notice to your, you're an academic, you're an assistant professor, I presume.

Pittsburgh is also a very serious place as academic. I interviewed there once. It's a no-nonsense kind of institution.

It's not one of these California kind of places. Pittsburgh is pretty serious. I worked there, too, in California, so I know.

But what was their response?

[Marc-David Munk, MD]

Oh, they're terrific, the Pittsburgh guys. I mean, I became a great doctor training at Pittsburgh. It's one of the country's best programs for emergency medicine, and people have been, over the years, just so generous, and I've made terrific, terrific friends.

Listen, emergency medicine are not, we're known as being sort of slightly flighty folks with a real sense of wanderlust, so I don't think it was a real surprise that I was looking to do something different, to be honest. But yeah, they were fine with it. Did they say you could come back?

I, gosh, I'm not sure if I asked them specifically.

[Andrew Wilner, MD]

I mean, did you come back? Did you go back? Did you return there after your first time?

[Marc-David Munk, MD]

No, I ended up, after I came back from Africa, I ended up actually doing two things. One is I took a new job in New Mexico and decided to move south and take an academic job in the Southwest for a bunch of reasons, part of them weather, to be honest. And I also decided at that point to go back to business school, newly inspired by Africa.

And that's, it's a bit funny. People are like, why did you go to Africa and become inspired to go to business school? How does that all fit together?

But I was, I realized in taking time, and you can see this reflected in the book in some chapters, that I really wanted to start thinking hard about better ways to deliver care. And I realized that if you didn't understand how it's organized or how the money works or how leadership works, you just didn't have the tools you needed to decipher things or to create a better system. And so that was the opportunity for me to start to apply to schools and to go to school for a couple of years part-time.

And that was my next path.

[Andrew Wilner, MD]

So I guess, should I add MBA to your credentials?

[Marc-David Munk, MD]

No, it wasn't an MBA. It was actually a Master of Healthcare Management degree, but close enough.

[Andrew Wilner, MD]

All right. So then somewhere along the way, you said, I got to go back to Africa. How did that happen?

[Marc-David Munk, MD]

Yeah, 2012. And I was a little bit bored, as tends to happen sometimes. And I wanted to go back and get back in the field.

And so I took some time off work. They were good enough to give me a bit of a gap and got on the plane and ended up back in Nairobi with the old crowd. Most of them are still there.

My nursing colleagues and the leadership at AMREF. Most of them are still there.

[Andrew Wilner, MD]

Wow. So now the first time you went, you didn't really have to justify this decision to anybody. As I recall, you're a single guy.

You're fine in your way. You're established. You got enough money in the bank.

They do pay you, though, in Africa enough to...

[Marc-David Munk, MD]

Nope. This was a volunteer gig.

[Andrew Wilner, MD]

Ah, it's all volunteer. So they just provide a little breakfast and a place to sleep.

[Marc-David Munk, MD]

They provided some snacks and good coffee and a place to put your head. But yeah, pay wasn't the attraction here.

[Andrew Wilner, MD]

But, I mean, if you had had a mortgage or something like that, I mean, the bills continue even if you're away. So you didn't have any of that.

[Marc-David Munk, MD]

And by 2012, this was a bit of a different story for a couple of reasons. I mean, I was newly married by 2012. And so for the first time, there was somebody who actually was worried about me flying in East Africa.

Our kid would be delivered a couple months later. And so I realized that the stakes were much higher this time around. But I also realized if I didn't do the trip then, you probably would never do it again for all those reasons that you've mentioned.

And so it was a big sort of a last hurrah perhaps. What I did notice was that Africa was a really different place the second trip compared to the first. So I would say in 2008, the trips, the cases were probably similar to the kinds of cases that Tom Reese and his colleagues treated when they were there 20, 30, 40 years earlier.

There were surgical emergencies and car accidents and cases of malaria, other tropical illnesses, those sorts of things. By 2012, what had happened was that there was a big outburst of Somali terrorism that had really rocked East Africa. And if you remember back, I mean, there had been cases of really serious terrorism where malls in Nairobi had been attacked by gunmen and there were cases of terrorism up the coast by Mombasa.

And East Africa had become a very unstable place. And as a consequence, the work that we did at Flying Doctors didn't in many ways resemble the work I had done four years earlier. Instead, we were flying on a regular basis into Somalia to pick up African Union soldiers and aid workers and others.

And this was a new level of hairy work. I mean, we had on one occasion an American soldier who we brought to Nairobi. He got sick at sea and they brought him to the coast and then we picked him up from a military helicopter and brought him to Nairobi.

That was one of the stories in the book. But between flights picking up soldiers and flights to Somalia for victims of terrorism or to concentration camps slash refugee camps in the northern part of Kenya, boy, I mean, things were much hairier and much different the second time around.

[Andrew Wilner, MD]

All I can see is what I remember from a Mad Max movie of just lack of government and just kind of wild, you know, just people whoever has the biggest guns kind of in charge scenario. All right. So that's 2012.

And then another decade goes by until you write the book. Is that right?

[Marc-David Munk, MD]

That's right.

[Andrew Wilner, MD]

That's true. So one day you just said, you know, I need to write this book. How did that happen?

[Marc-David Munk, MD]

I don't know exactly what inspired me to pick up the book, but I knew it was on my list of things to do. And I had some time to actually crank this thing out. And so I went back and started-

[Andrew Wilner, MD]

Was it a COVID project?

There were a lot of books that came out of COVID.

[Marc-David Munk, MD]

Yeah, maybe. Yeah, it could have been related to the time I had in COVID. I was doing a new job that required a lot of global travel.

And I was spending a lot of time on airplanes. And one of the things I found on these international trips is that it was a great space to write. It was not a lot of interruptions.

But the other thing that I found writing in the air was that for some reason you seem to be much more emotionally attuned at altitude. I don't know whether it's a mild hypoxia or the free glasses of wine that they give you on the flight, but I felt much more able to dive deeply into thoughtful questions and sort of life, big questions about life, big questions about what I had seen, big questions about what they meant. And I was able to really approach them, I think, on a far more honest emotional level than you can do when you're sitting in your office and the pager's going off and you're interrupted all the time.

And so that's probably what created the space.

[Andrew Wilner, MD]

Right. I'm happy that you found that space. And I would agree with you that that space is harder and harder to replicate, you know, with the phone and the pager, which hasn't changed much in the last 30 years.

It still can find you anywhere with the same annoying tone. But you're right, in the air, I used to commute from one job to another as a locum tenens physician and I would have three hours from Phoenix to Minneapolis and I'd pull out my laptop and I had a chance to kind of zone in and you're right, nobody really bugs you much in the plane. You know, they're happy to be in their own cocoon and, I don't know, it's not really a sustainable kind of writing approach unless I had my own plane and pilot.

But you took advantage of those opportunities and I'll just mention since we're into this about 25 minutes now that your book is available on Amazon and it's available on audiobook and I highly recommend, certainly the audiobook, you've got a great radio voice and, you know, when you narrate your own book, which I did, the kind of the flow, it's very natural because you're reading the words that came out of your mind so you don't really have to practice too much I don't think.

I certainly didn't. It just came out because I wrote it so I know how it goes and so I think it's a special treat to listen to a book that's narrated by the author. I'm not a big fan, generally, of audiobooks, you know, that even if the guy is very, very good who's narrating it, he's not the one who wrote it and there's just a distance there between the written word and the voice which is not there in your case.

Okay, so with all of that as a preamble, you noticed, you know, if your book was fiction, right, we have idealistic medical student, disillusioned ER doc, adventurer in Africa, and a lot of self-discovery, come back with a purpose, so fix the healthcare system because you saw all these inequities, got a million dollar plane and they got people who don't have a band-aid, right, how do you balance all that?

And then you come back to the US which has a pretty big healthcare budget and yet there's a lot of inequities and unavailability, there's a lot of availability problems, accessibility, I just had a routine test, it took me two months to schedule and I've got great insurance. You know, how do we fix all, and I'll just mention for those interested in this, if you just scroll back, there's two programs that I've done recently, transformation, transforming the healthcare system, one of them is with a former congressman who was one of the authors of Obamacare and is now working in the healthcare space, trying disease management which is something I also do, one is a medical student who's a pretty bright guy and also very interested in disease management and improving the healthcare space and so now I've got you. So what are you doing now?

[Marc-David Munk, MD]

Well, so I'll give you my trajectory, it's a little bit unusual, I would say the first third of my career was academic emergency medicine, the second part of my career was really healthcare administration but I really wanted to focus on trying to improve the system, I mean you and I both know that fee for service and the greed prerogative are destroying American medicine and they were back then and I think one of the things that my travel in Africa impressed me with was just the importance of face-to-face medicine, like the, you know, we I think are so good at complicating medicine here and driving such a profit motive and institutionalizing it that we forget sometimes that the entire reason the entire system exists is for these few moments of interaction between patients and doctors, like everything else is just this infrastructure that we created around these seminal moments and it was flying daily, seeing patients at the worst time of their lives with the most severe illnesses and spending hours and hours with them in the back of a small plane flying across the savannah that just impressed upon me how important this work is and how grateful we should be to be doing it and how we've gotten so far away from this essential work and so when I came back I wanted to think of ways at an organizational level, at a systems level that we can improve medicine to enable doctors to deliver the kind of care that they really want to deliver to get away from this nonsense of fee-for-service billing and just the crap that we put up with here on a daily basis and so when I went into administration I really vowed that I wanted to work in alternative care delivery spaces so initially worked for capitated medical groups that were taking a per member per month payment that really unlocked a lot of innovation because then instead of having to bill for these endless visits and DRG codes you could suddenly just bill a flat fee and deliver the kind of care that patients needed with the minimum of bureaucracy they were a bit of a dying breed I mean I was lucky enough in Massachusetts to come across a few and there were handfuls of this California had them and Minnesota and Massachusetts did but they were a really great introduction to thinking a bit differently about this care delivery that we weren't bound I mean fee-for-service isn't written in stone it's something we made up it's just a way of compensating for care and there's other ways to do it that are more intelligent and left there and ended up working for a primary care startup that went national it was a senior primary care startup that got quite big and was delivering great care under a Medicare Advantage payment model back in the day that was ultimately sold to One Medical and then went on to be sold to Amazon believe it or not down the road and then did consulting overseas mostly in this accountable care delivery space where I was really trying to figure out ways again to get away from this horrible fee-for-service incentives and to deliver a more holistic type of care and then made what I would say is the third pivot which has been to palliative care and I've been for the past year training as a palliative care doctor I've taken a break from the administration and am just finishing in the next few months palliative care and then I'll stay on as faculty delivering palliative care at an academic center

[Andrew Wilner, MD]

Yeah, so you know there is this problem and we've done programs on it about physician burnout and one of the things one of the recommendations that's often made and I did have a physician on this program who made the recommendation is to go do a medical mission because when and it works doctors do medical missions who volunteer go to some underserved place which is not necessarily overseas there's plenty in the U.S. and give their time for free so it eliminates all that infrastructure you're talking about and billing you're just seeing the patient and you spend as much time with them as you can as you have depends how long the line is I mean like you sat for hours in a plane with critically ill people who can do that?

Who gets paid to do that? Nobody and yet there's a famous painting I think it's I'm trying to remember the name Sir Luke Fildes it shows a physician at the bedside of a very ill girl must be 200 years old and he's just sitting there holding her hand and maybe he's taking her pulse but he's there and he's there all night because she's ill probably with some modern preventable disease that was not preventable in those days being present and being there and you can just feel the compassion that comes out of the because that's all he had didn't have antibiotics but they had compassion and I think physicians miss that greatly in their day to day because of speed you get paid for more productivity RVUs and all of that there's nothing wrong with being productive and working hard but if it eats into what you're trying to accomplish if it diminishes the quality of your product they always talk about violins how do you make a violin well you don't make a violin in a Chinese factory somebody's got to select the wood and build it carefully I don't know how long it could take weeks or months or years to get it right but if you just paid on the number of violins you're not going to do it that way so there's got to be a way to get back to making a better violin how does palliative care work aren't you just paid for your visit

[Marc-David Munk, MD]

yeah the compensation model for palliative care is really unacceptable I mean palliative care doctors will spend sometimes an hour plus with new patients and we see them regularly and a lot of this is time intensive you can't rush a palliative care visit and at the end of the day we bill you know a standard level one level two level five visit which frankly doesn't pay the bills and so nobody has ever come up with palliative medicine centers of excellence because it's not a big revenue driver and in fact for most systems it's a loss leader but it's essential work and so I think to look at it on the basis of that kind of a metric is really the wrong way to look at it. If you were to compensate a specialty on the basis of the outcomes it generates in terms of management of symptom burden thoughtfulness about end of life planning things that are valuable to patients who are sick it would be compensated in a different way but it isn't because we're set up the way we're set up. It's interesting getting back into the academic space at this point because I've been away now for more than 10 years and I'm struck by just how crummy things look generally speaking.

And I think part of the problem if you've been in academics for the past 25 or 30 years is you're a frog in a boiling pot. Having stepped away and stepped back I'm struck by the meagerness of health care system in America today. There are a couple outliers fancy medical centers with huge endowments that have very well compensated private patients and international patients and they seem to be doing okay but frankly for the majority of hospitals and clinics and doctors offices in the country things are just so meager.

The places look scruffy and the facilities look tired and there isn't enough administrative staff to keep the wheels running and things are falling through the cracks and it's only through these heroic measures undertaken by the doctors or the doctor's staff that actually keep the wheels turning. The special call that somebody needs to make, the insurance company call because the $10 medication was refused, you look around and you're like these places used to be more highly functioning if you can believe it and all of the niceties that we used to have, magazines in the waiting room, cups of coffee for patients, they're just gone in the name of cost cutting. Things are just meager looking, cut to the bone.

[Andrew Wilner, MD]

Reimbursement, Medicare had another cut this year. Doctors who are depending on seeing the same number of patients, cost of running your business, inflation, that goes up and the payments don't. You're forced to see more patients, make less money, but you still have to pay the overhead and at some point it's not worthwhile and it's not fun.

Also, I think it's a lack of investment in the future because you're not going to build a shiny new office if you see your revenues going down every year. You only do that when you think things are going to get better and we're going to grow into it. When you see the sun is setting and not rising, I think that's very problematic.

You mentioned academia. I've been in and out of academia all my life, currently in, so I'll moderate my comments, but academia is under fire because they're under the RVU system. They're being forced to produce, but that's not their job.

Their job is to educate, to do research, to intellectualize, and take care of patients. It's a different mission, and if that mission is only measured by productivity, it's a set-up for failure. You only saw three patients today.

Each one took three hours because they've got recurrent cancer in 17 different places and we're thinking about a novel checkpoint inhibitor that's never been used in this situation. That's not McDonald's. That's not a drive-through get an RVU and move on kind of scenario.

I'm exaggerating, of course, but I think that is a huge, unsolvable problem for academics to be measured the same way as everybody else because they're trying to do something different, and they can't. The academic mission is falling. It's much harder to be quote, academic.

I remember when I trained, there were many more conferences and rounds and sit-downs and times to get deep into what was going on because we didn't have RVUs back then. Under the RVU pressure, every minute of your day has to be scheduled to be RVU productive, and if it's not, then it's obvious. It's obvious.

[Marc-David Munk, MD]

Let's look at this. It's such an interesting point. We, as a system, dump more money into healthcare than anybody else in the world, whether it comes from employer premium contributions, whether it's things that we pay personally.

As a consequence, we dump mountains of money into the healthcare system, and yet when you finally get to the end of this big river where the patient finally meets the doctor, the clinic doesn't have enough to repair the otoscopes. I've had friends send pictures of their emergency department and the chairs are falling apart and held together with tape. There isn't a penny left.

The question you have is, how can we start with a flood of money at the beginning and end up with a trickle for the core purpose of the experience, which is the doctor meeting the patient and delivering service? My theory, and I'm writing a piece about this, is that there are so many interests that have ingratiated themselves into the system over the years who have no restrictions on the amount of tax that they pass on to the ultimate buyer of services, that all of the money that is dumped into the system is sucked out over the course of the flow of the river until it gets to the end and there's just a trickle of water left. And if you take a look at things, the insurance companies, we love to poke on the insurance companies, but if you are managing a medical loss ratio of 80 to 85%, you've kept 15% of the money for yourself.

You've kept it for yourself to deliver these vague services that you claim are so important, which in most places aren't needed, most countries aren't needed. These care management programs that they run, these prior authorization programs that are onerous, things that have proven not to work and they persist on doing, they can charge 15% and nobody asks the money. You get down to the PBMs, who knows how much money they keep because it's such a black box of moving money between pockets that nobody really knows.

But you get down even to the small stuff, Andrew, which is things like state license renewals, things like library memberships.

[Andrew Wilner, MD]

story.

[Marc-David Munk, MD]

Well, I mean, they go on and on. The journal subscriptions for the medical libraries are thousands of dollars. So the researchers produce it for free, review it for free, give it to large companies like Elsevier which have rip-roaring margins, those guys, two major medical publishers.

They then give it to the medical libraries at a highly inflated price that the library needs to pay for, otherwise you don't have journals to consult. And it just expands across the spectrum, the professional organizations, the American boards of this and that. Take a look at how much money they have in the bank, how much money they've saved up over the years, what they're paying their executives.

Take a look at the joint commission as an example of how much they're paying. Take a look at the press organizations that are mandated to collect experience and look at how much they raise. My point being there is more than enough money in the system to pay for coffee for patients.

There just is. And there's more than enough money to pay for longer visits. We're in a system now where there are no breaks on what people can charge along the way and they have made it from a policy perspective and a regulatory perspective and they don't want to give up those revenue streams.

As a consequence, when you and I end up in a room with patients, it's like rubbing two sticks together to fly to the moon. There isn't money to do the basics. It's outrageous.

[Andrew Wilner, MD]

The patient ends up incidental in the process. That was depressing. Any light there?

Is there anything you or I or anyone can do to fix this or will it die of its own weight?

[Marc-David Munk, MD]

I think it will have to die of its own weight. We've been trying for decades to get a handle on this and it gets worse year on year. I've come to the conclusion that in the absence of big policy reform, the market is not going to untangle itself and fix this problem.

This is not a market where free market solutions are going to fix these issues. There have to be regulatory restrictions put into place. This is what the U.K. and Canada and Western Europe and Australia have done. These things need to be regulated because they're a public good. I don't know how this is going to happen. We're in an unusual time right now.

My instinct is to see patients and derive joy from doing that and wait to see how things shake out. If things can't go on the way they are, they won't go on.

[Andrew Wilner, MD]

Palliative care. We started a palliative care program As a neurologist, we were often in the palliative care space with patients who were comatose and not waking up. We would get called by the other teams to have that long and painful discussion about what to do as the experts in that area.

Now that we have a palliative care team, a lot of that has been offloaded and appropriately to them. They don't have to deal with the medical management, they're dealing with the psychosocial management going forward. I've been thrilled to have their help so we can do more of what we're better at.

The patient has this bonus now of having support. When we're making rounds, I think it's time for palliative care. That's a code.

I don't think we're getting where we want to go here in terms of making the patient better. People don't get better indefinitely. None of us get better.

That's unfortunate in many respects, but that's where we live. I want to know, are you keeping detailed journalistic notes?

[Marc-David Munk, MD]

I've been so overwhelmed by the avalanche of new information and absorbing it that I haven't been keeping the notes I need to keep. I'm not sure I've fully reconciled these stories well enough to write about them thoughtfully. Palliative care is something we underutilize in this country.

It's dramatically underused. We should be getting involved earlier. We can focus on the symptoms where the oncologist is working on a cure or disease management as opposed to symptom management.

We provide a second set of eyes to say you know this patient well and you've been following him for ten years. I want to provide for you an independent appraisal. It's hard when you're following these patients in these journeys and they become friends.

It's easy to lose your objectivity. That's where palliative care adds value. We're facing a demographic crisis.

The population is only aging and we don't have enough palliative care doctors. I hope I can encourage anybody listening to look at this as another career option. It's a beautiful way to finish your career in medicine.

[Andrew Wilner, MD]

This has been a fantastic discussion. I got to find that guy. You're not that easy to find.

I finally found a website somewhere that had info at Marc-David Munk. You responded thankfully. You're not one of these self-promoting people.

It actually took some work to track you down. I'm glad I did. Before we wrap up, is there anything you would like to add?

[Marc-David Munk, MD]

This has been a terrific conversation. Thank you so much for the opportunity to come on your show and vent a little bit. I think it's like a catharsis.

We feel so much better at the end of these conversations.

[Andrew Wilner, MD]

Thanks for joining me on the Art of Medicine. Now a final thanks to our sponsor, locumstory.com. It's a free, unbiased educational resource about locum tenens.

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Andrew Wilner, MD, is Associate Professor of Neurology at the University of Tennessee Health Science Center, Memphis, Tennessee. Views, thoughts, and opinions expressed on this program belong solely to Dr. Wilner and his guests, and not necessarily to their employers, organizations, or other group or individual. While this program intends to be informative, it is meant for entertainment purposes only.

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