A conversation with the peripatetic Dr. Jordan Shlain on the “hairball” of healthcare, insurance companies, sugar in our food, and why you have to keep filling out the same form over and over
Dr. Jordan Shlain is a fixture in the Silicon Valley scene, a sharp witted, opinionated, and always on physician whose unusual career includes founding several health-related companies, inventing a new approach to private practice, co-founding a non-profit dedicated to redefining society’s approach to sugar in our foods, and launching Tincture, a publication which seeks to elevate our cultural conversation around health. Shlain also frequently flies to Washington, DC, where he speaks to policy makers about the frustrating realities of healthcare as a practicing physician.
Shlain is also a close friend, and he happens to be my doctor as well. He’s deeply connected to nearly every specialist in the Bay area and beyond, and is certainly a good man to know should you ever find yourself in a complicated or challenging health crisis. His approach to patient care is not for everyone — his practice, which has offices in San Francisco, Silicon Valley, and Los Angeles, is high end and quite selective. But while many doctors are experimenting with atypical approaches to primary care, Shlain stands out for his outspoken beliefs about how our healthcare system is broken, and what it will take to fix it.
As a friend, Shlain was my very first interview subject for Shift Dialogs. I recently reviewed the entire transcript, and thought it well worthy of publishing in full. Below is both the video interview, which has been edited for length, and the full transcript, in two parts, edited for clarity.
John Battelle: At the center of your engagement with medicine is your primary care practice. You run it in an unusual way — you don’t accept insurance, for example. What else makes it unique?
Jordan Shlain: We’re a group of like-minded doctors, internal medicine doctors, pediatricians and naturopaths, all working together to conspire for good health for our patients. We try to not be influenced by the current medical system in terms of how to take care of people. We try to focus on A, what matters to you, and B, what’s the matter with you.
What matters to you? That’s usually not why you see a doctor. You see a doctor when something’s wrong.
That’s “what’s the matter with you.” Oftentimes people come to doctors loaded with anxiety, and with preferences — they want an aggressive solution, or a conservative one, or something in the middle. In order to draw out what the best approach for that person is, you actually have to spend some time listening and understanding what makes them tick, and how they want to exist in the context of medicine. We spend time trying to understand what matters to you in the context of what’s the matter with you. I often argue that there is no evidence for ‘evidence based medicine’ when you’re dealing with a single patient. The evidence that we often refer to is used to manage populations…I don’t manage populations, I advocate for people, in all their unique glory.
Most of medicine is, “What’s the matter with you? Here’s the treatment.” There are no options. They layout for you, “Go get that blood test. Get that surgery. Get that injection,” without a longer conversation about what the options are. There is no right answer for what to do, often. It’s not binary. It’s a lot of grey.
This feels like a different approach to how people should be or might be interacting with medicine. How did you get your start?
Back in 1997 when I finished my training here in San Francisco, I joined a doctor — an older guy — and he said, “Hey, Jordan. You work for me for one year, and I’m not going to pay you very much. You’re going to see a lot of patients. You’re going to cover me on the weekends, but in a year I’m going to retire, and it’s yours.” I thought, “Great!”
On month 11, having made very little, worked very hard and spent a lot of weekends on-call for this guy, he basically said, “I’m really enjoying this arrangement. Let’s do this for a couple more years.”
Sounds like a venture capitalist.
Right? I looked at him like, “Are you kidding me?” He said, “No.” I said, “Look, I quit. I’m out.” He was like, “You’re not going to quit. Doctors are super-conservative. They have school debt.”
But I walked out the door, kind of in an existential crisis at that moment, having spent a lot of years in medical school.
You’re a young doctor at this point.
Yes, a young doctor. Thirty years old, having finished UC Berkeley, then the salt mines of Georgetown medical school, then three more years being overworked in the hospitals of San Francsico.
I was walking down Montgomery Street, not really sure what to do. I walked by this hotel and decided I’d go in and have a cup of tea and contemplate my life.
I happened to have walked in to the Mandarin Oriental Hotel, which I had never been in before. It was a five-star hotel. As I was I was having my tea, I saw these fancy people coming to the concierge desk with questions.
The concierge desk was very busy, but things were happening like that [snaps]. I walked up to the concierge desk, trying to think out of the box, and I said, “Who’s the doctor that you call when someone here gets sick?”
This woman was the concierge with all the lapels pins, the fancy, five-star concierge. She goes, “Who are you?” I say, “Well, I think I could be the next doctor for this hotel.” She said, “You’re a doctor?”
I said, “I am,” and she said, “Well, with all due respect, doctor, I may be one-star smart, but everything we do here is five-star service — from the linens to the limos to the lunches, everything.”
She continues, “My guess is, you’re five-star smart, but everything you do in your industry is one-star service. If you even want to think about being the doctor for this hotel, you have to do five-star service. We take care of presidents, kings, movie stars, NBA all stars etc.”
I looked at her and said, “Teach me.” She didn’t know I had nothing else to do right at the moment, and so she kind of took me under her wing and gave me a Mandarin Oriental-style, five-star concierge training . A lot of it it’s common sense. You have to listen. You have to follow up. You have to be reasonable. You have to be empathetic. You have to bite your tongue sometimes. All these versions of what five-star service is, and you’ve got to put your best foot forward, you’ve got to look sharp, you’ve got to not be sloppy.
Shortly thereafter I got the gig, and was taking care of prime ministers of countries…
Wait, wait. From talking to the concierge at the Mandarin to getting the gig…Was that a few weeks, a few months?
It was about a month of her checking me out. She called the hospital. She called the medical society. She wanted to make sure I was really who I was. My father happened to be chief of surgery at the local hospital, so it didn’t hurt that you could look him up. I’m not just, say, some dude of the street that walked in.
She credentialed me, I spent some time with her, and then she goes, “OK, I’m going to send some clients your way, and I’m going to get feedback.” She said, “But rule number one is you’re giving out your pager.” It was when pagers existed, and cell phones and email were just starting to come online, and I gave those out, too.
She said, “When I call you, you answer the phone in the first three rings. If I page you, I want to hear back in five minutes.” Again, I had nothing to do other than try to figure out my future.
I saw the prime minister of Japan, and movie stars, and Fortune 50 CEOs and Senators. I got good feedback from her. I tried to do everything she said. If they needed to go to specialists, I arranged it. I followed up.
Later on, she said, “Feedback’s good. Keep doing it.” So I walked up to the Ritz-Carlton a month later and said, “Who’s the doctor for your hotel?” They said, “Who are you?” I said, “Well, I’m the doctor at the Mandarin.”
All the concierges…
They all talk.
They’re all mobbed up in a certain kind of a good way. One thing led to the other, and — in about a year and a half — I built a little group and became the doctor to all the hotels in San Francisco during the Internet boom of 1999 to 2000. I learned business and entrepreneurship. I was doing something that was wholly new.
This is not the normal path for a doctor.
No. My whole life is somewhat accidental, but directionally I know that being a good doctor and taking good care of people is my North star. How you get there in a system that doesn’t want you to do that, a system more interested in cycle time, is the question.
Today’s healthcare system doesn’t want you to do that. The typical approach is that we get to see doctors for as little time as possible. Why is that?
Having worked in that doctor’s office where I had to see 30 patients a day, it was literally seven minutes a visit. I kept getting a [knocking] , “Dr. Shlain, your next patient’s waiting. You’ve got to hurry up.”
Seven minutes a patient.
I never finished listening or educating or trying to explain.
When you’re in a mode where you’re on the hamster wheel, what the patients wants is, “Doctor, don’t just stand there. Do something.” But often in medicine, the best answer is, “Don’t just do something, stand there.” Not doing something can equally as beneficial as doing something. Oftentimes it’s more beneficial. But in order to get someone to buy into doing nothing and waiting, they need to have trust and faith that A, you’re competent, B, you’re going to be there if anything goes wrong. There’s all these components that conspire against good care in today’s model.
I think it’s important to understand how we got there. For most of history, medicine’s been a cottage industry. Doctors over there charge that, doctors over there charge this. Then someone said, “Hey, you know what? Why don’t we just say we’re going to pay doctors X, line them all up, get them in a contractual rate? We’ll go through this third-party system where employers will pay insurance companies.”
It used to be patients paid the doctor. That’s the old way. When you’re the recipient of the money, you have a responsibility to provide a service. People can go to the other doctor.
But as soon as insurance companies formed and networks formed and in-networks and copays and deductibles, now you gave money to a third party. That third party paid the doctor. You weren’t actually paying the doctor.
The relationship was broken.
It’s called the principal–agent problem, in political science and economics. It occurs when one person or entity — the “agent” — is able to make decisions on behalf of, or that impact, another person or entity — the “principal.”
One day when I was at the old doctor’s office in San Francisco I received a letter, as a patient, saying, “Dear Mr. Shlain, as a valued member of Blue Cross insurance we want you to know that your rates will be going up by six percent this year, and the reason we’re doing that is because we have to have better quality, and we’re putting in new systems,” and a bunch of language like that.
As a person who is paying for insurance, you figure, “OK, your rates go up six percent. I guess that’s the way insurance goes. You can’t fight it.” It was signed by Leonard Schaeffer, the CEO of Anthem Blue Cross.
The next day I got a letter, same envelope with the blue cross, “Dear DOCTOR Shlain, as a valued doctor in our network we regret to inform you that will be decreasing your fees by three percent this year.”
A nine percent swing for the middle man.
The rest of the letter was the same as the other letter that I got as Mr. Shlain, the patient. That’s when I said, “Holy smokes, this whole thing is so messed up.” I wrote a letter to Mr. Schaeffer, the CEO of Blue Cross, and I said, “I’d like to talk to you because I’ve got these two letters that I think The Washington Post and The New York Times would love to see. I want to talk to you about this.”
It got kicked all the way up to his chief of staff. My father in his sage wisdom said, “Jordan don’t do that. You’re just starting your career. The last you want to do is poke that skunk at the highest levels.”
So I buried that drama.The thing is, if you take the, “Dr. Shlain, we’re going to decrease your payment” each year, it compounds, and if I want to make the same amount of money I did, assuming my expenses are going up and my income is going down, you know the only lever I have?
More patients.
More patients per day. Then that means less patient time per visit, and it means more prescriptions and more specialty visits. By squeezing me, the primary care doctor, it causes more drugs, more surgeries, more everything else, which causes the whole system to become more expensive, because I’m the cheapest guy in the food chain as a primary care doctor.
Everything else is expensive. This is a totally messed up system that continues today. The good news is the leadership at Medicare is trying to solve this through an outcomes-based approach, as opposed to a transactions based approach.
End of Part I. Read Part II here, which covers the role of sugar in health, food labeling, and more.