Judson Howe If I were to walk through BMC today and I said, who really is Dr. Katherine Gergen Barnett, what would they tell me?
Katherine Gergen Barnett First, they would say, you mean Dr. KGB? Because that is my moniker. It appears that that has become what most people call me, although I know it's not politically — it's complicated, right?
Judson Howe Is there an FSB as well?
Katherine Gergen Barnett But what is so ironic about it is that I'm very, I think, earnest and hardly secretive about anything. But I would think people would say if you're really walking through the hallways at BMC — you know, I've been at Boston Medical Center for 20 years. I did my training there. I've worn every different hat. I think people would say, first and foremost, she's somebody who deeply cares about her patients. And I've, again, taken care of multi-generations for years in all different contexts but also really focused on primary care and thinking about how can primary care be the driver for better health outcomes for our community. So not just working within the clinical setting or the hospital setting but also working in the state legislation setting, working on the federal level for primary care policy and support. And so really thinking about championing my patients, the needs of my patients, but also the needs of our specialty.
Judson Howe Take me to a moment in your childhood where you're like, this is what I want to do. What created that?
Katherine Gergen Barnett I certainly wouldn't think it was my childhood. I grew up in the outskirts of Washington, D.C. My father worked in the White House and the administration, and my mother was a kindergarten teacher. And so I always had this perspective that service was our call to action. That's how we are meant to live our days. That's how I watched the modeling of the world. So I felt a deep yearning for some sort of service and connection. I initially was really drawn to work in public health, and I thought I wanted to do medicine. But I will say that when I got to college, I met a lot of people who were in the pre-medical track, and those were not my people. I've since become very allied with and found my kindred spirits, but to me the question of medicine was how do you take care of the whole human being> How do you meet sort of the human in the context of their body and their community? And I didn't see that yet in medicine. I really saw it as formulas and the science of it. And it was really when I moved to San Francisco and I was working in the HIV community. And this was right when antiretroviral therapy was coming out and I was getting to be at this nexus. I was doing advocacy and policy work and public health, and I was at this nexus of people for the very first time weren't being given a death sentence who were living with HIV. For the first time, they had an opportunity to have access to medications. And yet it was a really complicated time, right? Because on one hand, you'd think that people would just be jubilant. But on the other hand, many people had already driven themselves into deep debt or had the sense of okay, this is the door that's closing. So it was complicated —
Judson Howe Clarify where that debt came from. What debt?
Katherine Gergen Barnett From thinking I'm going to die. I'm just going to live off — I'm not going to have savings.
Judson Howe Like, you only live once, YOLO?
Katherine Gergen Barnett I’m not going to have savings. I'm not going to live with savings. I don't need to plan for the future. And so how do you kind of have this nexus point of both saying, actually, this is a chronic disease now, and hitting both the joy of that and the complicated feelings around that, and seeing the people that I admired most who were doing that work, who I just learned a tremendous amount from, were those people who were in primary care. Because they were able to do the medical part, but they were also able to do the advocacy part for these patients and also think through the greater kind of implications of policy, what was happening on the grounds in, at that time, San Francisco. And I was really drawn to, I was on a bunch of boards at the time, really trying to understand that intersection. And that's what drove me to go back into medical school.
Judson Howe Do you think that experience at that time was unique to San Francisco? Or would you have found that in DC, Boston, Philadelphia, Midwest?
Katherine Gergen Barnett No. You know, only in the conversations that I've had with people since and kind of squaring up all the narratives. I'm going to be really curious to hear from your listeners as well, for those who are doing this kind of work. I absolutely think that was happening across the nation, but in different ways, right? It depends how those conversations were unfolding. Being in San Francisco was sort of the heart of where the epidemic broke out and where, as we know, a lot of people were marginalized because it was considered specifically an infectious disease among gay men, which we know was obviously completely a fallacy, right? But that was the way it was understood. I think there was such a wonderful infrastructure that already exists in San Francisco, so it was able to turn on a dime in terms of the advocacy that patients were able to receive.
Judson Howe As you're talking, I'm just reflecting on myself. I've also been shaped by Northern California. And in many ways, I only have a sample size of myself in a lot of these things. Do you find that family medicine is different regionally across the country?
Katherine Gergen Barnett I will say having spent time in public health and policy work out on the West Coast and then coming back to the East Coast for medical school. I went to a med school that still doesn't have family medicine. So Yale is considered still one of the orphan schools.
Judson Howe In 2025, it doesn't have family medicine?
Katherine Gergen Barnett Correct. Harvard and Yale are two of the orphan schools. We still do not have family medicine training.
Judson Howe Why is that?
Katherine Gergen Barnett There is a lot to unpack there. I — we can go there — but I will say I was directly, I had chairs of medicine and others come up to me and say, you're too smart to go into family medicine, why are you doing this? And for me, again, it was the people I had had the privilege of meeting outside of these East Coast institutions that were truly doing, mind, body, spirit, taking care of the whole person and the whole community. And I was like, how can that be wrong? I will say, after 20 plus years of being a practicing physician as well as a healthcare leader, there are so many things I know now that I didn't know at the time, in terms of how do we get compensated for the ways that we take care of people? What are the ways in which we heal people that are not considered an RVU? And so I would say it's complicated in terms of why places like this don't have family medicine. Part of it, I think, is this idea that family medicine is not good enough. But really, I think a lot of it's driven from, you know, a financial modeling, right? Despite the fact that we actually do a lot of procedures, we deliver babies, there's a lot of ways in which we can accrue benefits. But it is, I think it's like considered a kind of this old fashioned, nice thing. It's not necessarily like a heart of an academic medicine institution, which we are working to change. And BMC has been a wonderful place to grow family medicine because it's right in the heart of Boston. We're the only academic medical center in Boston that has family medicine. And I did my training there. I'm training family medicine psychiatry joint residents. So these are people who are going to be family medicine and psychiatrists trained to truly address —
Judson Howe Is that unique to BMC in the nation?
Katherine Gergen Barnett We started the sixth program in the country. But it's a perfect fit for our patient population that have a huge morbidity and mortality and a huge burden of mental health.
Judson Howe You've just given me like five different avenues I can go down, and I'm trying to pick which one I want to go down. But I have a history in leading hospitals in rural America, where family medicine is a lifeline for us to keep our doors open and to create access to some of the most vulnerable populations that I've been around. Not saying they're more vulnerable than the urban areas, just a different expression of vulnerable. And so I have spent some time in and around family medicine. And in fact, one of the people on that journey I came across was a gentleman named Dr. Todd Stevens, who is the nephew of a guy named Gail Stevens. And I looked him up and it's like the Wesleyan model of family medicine and deep advocacy for FM as a specialty. And one of his early advocacies for FM as a specialty, family medicine as a specialty, was that he needs to have credibility against the biomedically assigned specialties. So enough about that side digression. I want to go back to, you're coming out of Yale Medical School, one of the top medical schools in the nation. You've been told that you're too bright for family medicine, which I now understand many family medicine physicians have gone through that same calculus —
Katherine Gergen Barnett Oh, absolutely. It's definitely a shared story.
Judson Howe What made you make that decision to buck that feedback, and to continue to decide to go down the family medicine pathway?
Katherine Gergen Barnett Look, I think that the fact that I had already come back into medicine as a choice, which was driven by the inspiration of people I saw in the field. When I think of other heroes of mine, like Jim O'Connell, who started Boston Health Care For The Homeless, somebody who sees the need and knows what tools you need and not being afraid. So the idea is that you think what's the voice you're going to listen to? Is it a voice of somebody who's going to tell you, this is the way that you become important, by these external accolades? Or is it a voice that’s telling you these are the people who need you and how can you best be of service? It goes back to the story of what I grew up with. So for me, family medicine is my way of being of greatest service to my community.
Judson Howe And you've already identified you're growing up in the shadow of the White House. And civic service is part of your family dinner table. So maybe that links, but I imagine other medical students also have an idea of civic service as well. Why would someone choose to go a different direction?
Katherine Gergen Barnett I mean, everybody is different, right? Again, I was most interested in not just the individual in isolation. I was really interested in what's the dyad between, say, a baby and her mother. What is the experience of a family in its community? So it's really thinking about the biomedical, social kind of experience of a human being, and family medicine trains to that extremely well. It's like this whole angles theory — and and it really um is the biomedical psychosocial it's like
Judson Howe What’s that mean?
Katherine Gergen Barnett It's the biomedical, psychosocial, it’s like really thinking about an individual in the middle of a circle, with family around that and then the community around that and the neighborhood around that —
Judson Howe Like pie slices?
Katherine Gergen Barnett No, literally circles.
Judson Howe Oh, concentric.
Katherine Gergen Barnett Yeah, concentric circles. And it's recognizing that what happens to the individual is absolutely connected to what's happening on every other part of those concentric circles.
Judson Howe So you mentioned biomedical science. And I think of someone dropped Vivek Murphy's epidemic of loneliness study, I think it was 2023, on my desk, and said, I can't remember what Dr. Murphy said, it was like 80% of physical ailments can be traced back to loneliness. Are we starting to see that? Are we starting to see the limitations of biomedical science in the framework of health? I'm trying to understand that.
Katherine Gergen Barnett Yes. So first of all, you should know that Vivek and I are good friends from Yale Medical School. And he and I were both leaders in something called Healer's Art, which was started by Dr. Rachel Naomi Remen, and it's all about how do you address the humanism in medicine? How do you talk about mystery in medicine? How do you talk about awe in medicine? How do you bring medical students and residents into a class like that when you're at a place like Yale? But any place, right? I ran that class for a long time at BU as well. And it's keeping medical students and residents and physicians human, because I agree with you. So if you're just thinking about biomedical, you're missing the whole person.
Judson Howe What are you missing?
Katherine Gergen Barnett You're missing all the psychosocial, and you're missing somebody in their context. And you're also missing, by the way, all the social determinants of health, which we touched upon earlier, you and I talked briefly about, right? So it's getting rid of this determinism that we have. To go back to Descartes, we really messed up around Descartes, right? The fact that we carved up a human being, and we said every part, the mind is different from the body, and you have to think about each thing really individually. I think it's taken medicine a really long time to come back to this idea that actually — it's fascinating. The gut has this incredible way of connecting to the mind. We have a nerve literally that's connecting from our gut to our brain.
Judson Howe A physical nerve you can look at?
Katherine Gergen Barnett Yeah, the vagus nerve, which is one of the largest nerves. And there's a reason that when you are incredibly stressed, you are going to have all kinds of gastrointestinal issues. There's a reason there's irritable bowel syndrome. Even though people feel like there's something wrong with them, your body is reacting to a stressor when you have irritable bowel syndrome, right? So the fact that we're now able to not make people feel like they're crazy for having these connections in their experience, or the fact that we're now talking about the gut microbiome. That's a whole other way of — first we talked about going way out, right? In terms of a person in the context of their community, in the context of their neighborhood, all that stuff. Now let's go way in. Let's talk about the tiniest little things that exist within your gut, right? The microbiome, and the fact that we have more cells that are not ours inside of our body than are ours. So in other words, you have all this bacteria that is not you, Judson, inside of you that is going to either make you well or make you sick, okay?
Judson Howe Could I call that environmental?
Katherine Gergen Barnett It is your environment. And now we're actually getting all this science behind it. How does the microbiome impact your health? And how do we actually make the microbiome healthier? So this is not woo-woo science. This is very good evidence. But because biomedical has been so limited in the way we understand medicine and science, it hasn't lifted its head up enough to understand that there's a much bigger way of taking care of human beings.
Judson Howe We're hinting around the hierarchy in medicine and, we have this biomedical construct that is one factor of many that leads medical students into certain residencies. You also hit on the financialization of healthcare.
Katherine Gergen Barnett Yes, we should talk about that for sure. A little hidden thing.
Judson Howe I told you before this call, I'm deeply curious about why some people, and I'm not trying to glorify FM more than — I see FM as part of an important set of specialties and they all play an important role, but to the extent that FM, family medicine is a symbol of sacrifice —
Katherine Gergen Barnett For sure.
Judson Howe I guess we agree on that. There are sacrifices that lead into that as well as other specialties. What led you, let's just go to you. You gave up a lot to go into family medicine, and I don't know quite how to quantify that opportunity cost, but I imagine it's large. Go deeper into why you would do that.
Katherine Gergen Barnett Before I go into me, I want to kind of go out a little bit and telescope out and think about what are the costs and what are the benefits. Myself included and many, many other family medicine physicians along the way — and by the way, there's so many ways to serve human beings and I'm like deep, deep respect for all of them. And within primary care, there's a million ways to serve as well. Not a million, five or six different pathways. But the benefit for me, for family medicine, is that I truly I get to deliver — perfect example. I'm taking care of a family where I met this young woman when she was in the pediatric emergency room years ago. She thought she was having a heart attack. She was actually having a panic attack because she was in a really rough situation. She didn't have a primary care physician. I gave her my card when I was actually carrying cards around. She came. She saw me. She established care. Within a year or two, she got pregnant. She's young, but she decided to keep it. She was with a partner. I actually delivered this baby. I took care of her whole pregnancy.
Judson Howe So you're a broad spectrum —
Katherine Gergen Barnett Well, at the time I was delivering. Now I just do way too many other things to safely deliver because I think it has to be a core part of what you do. I delivered her baby. I've taken care of her baby for all these years, who's now 19. And this mom is now 19 years older and got pregnant again, happily. And I took care of her whole pregnancy again. And I just went and I just, her baby just came and met me last week and is three days old and that's my newest patient. Those stories are so profound, right? And for me, there's nothing more beautiful than that intergenerational experience of people. That's one of hundreds and hundreds of people I take care of. The sacrifice is family medicine gets paid less. Pediatrics gets paid the least in primary care, from everything we just talked about in terms of RVUs that are generated. We don't get paid to counsel somebody on seatbelts, necessarily, or whatever, all the things that keep people well and everything that's being talked about right now and make America healthy. We don't get paid for that kind of thing. It's one thing to say, every physician should know about nutrition. Totally agree. Amen to that. We should all be talking nutrition all the time. Do we get paid to talk about nutrition? No. So let's talk about that. Let's talk about where are the incentives for payment, and how do they align with the ways in which providers will actually keep people healthier.
Judson Howe Yes. If you were Secretary of Health, what's the one thing you would be doing right now?
Katherine Gergen Barnett I would make sure every single person had a primary care physician.
Judson Howe That sounds like a workforce development. That's what that sounds like.
Katherine Gergen Barnett So primary care is the only, so the National Academy of Science and Engineering and Medicine came out with a paper a few years ago showing very clear evidence that primary care is the only specialty that improves health outcomes, reduces mortality, improves health equity.
Judson Howe What do the other ones do?
Katherine Gergen Barnett What do the other specialties do?
Judson Howe Yeah, if those are the only ones.
Katherine Gergen Barnett I'm not saying that they don't have good outcomes. I'm just saying as a triad of amazing outcomes, right? I think it's like A plus on the report card. And this is not just like an infomercial for primary care, but we're not talking about it enough. And guess what? We're right down the hill from the statehouse, Massachusetts statehouse. Massachusetts legislation is currently reviewing legislation that myself and others have helped put together are called Primary Care For You. And this is legislation that's specifically working to improve investment in primary care, improve their workforce. Think about when medical students are going into family medicine or primary care, that they actually don't have to repay loans, things like that. So how do you incentivize these pieces? How do you take some of the burden of responsibility off primary care shoulders? So, for instance, my colleague and I published a piece looking at all of the metrics that physicians need, primary care physicians need to account for. We counted up there 61 different quality metrics that we were accountable for at any different time. Guess what? It's because payers don't align with different metrics. So that's another thing I would do if I were HHS. I would make sure that payers all aligned on the same 12 quality metrics and said, these are the things that matter. These are the things that will actually change a person's outcome.
Judson Howe Irrespective of which plan you are, we want to standardize the things you're focused on.
Katherine Gergen Barnett A hundred percent. Every single payer should be agreeing on what outcomes they're asking of providers. So get everybody a primary care provider and ask primary care providers to do the same thing, standardize it and make us excellent and give us the tools to do it.
Judson Howe I want to bring it back again to your practice and to the exam room. Give me a story about a patient who changed the way that you practice medicine. Again, I've had the honor of so many patients being in my life. I was thinking about, when you asked this, I've been thinking a lot about one of my patients who actually died from stage four metastatic cancer. I met her when she was already had cancer, it was already metastatic. So I was with her on her last chapter of her life, which is really — you know, in medicine, obviously your listeners know this, you're constantly thinking problem-solution. Like somebody tells me a problem, I'm going to find the solution. When you already are meeting somebody for the first time and they know they're going to die — I mean, we're all going to die, but she really knew she was going to die. You're meeting somebody at a really different point of their life. She had a lot of other needs that she had for me, obviously her pain, her depression, taking care of her kind of final issues that she had in her life, wrapping up her life. And she really wanted to see me. Every week, she wanted to see me. And I will say at first, I was like, well, that's really bold. You know, I barely have like space for really brittle diabetics. But I made space for her every week, and she became a real teacher for me. Not only would I take care of her medical needs, but she would tell me about the history of Boston. She was a real civil rights organizer in the history of Boston, and she had this incredible legacy. I felt just so blessed to get that time with her and learn from her. I think I became less afraid of having this idea of, I'm the doctor and you're the patient. This was still early in my career when it was very schooled inside of me that it was a one-way street, and that I was there to serve her. It became clear to me that actually her healing — even though she couldn't be fixed, right, she was going to die — the healing for her was the fact that I was in a human relationship with her, and I was able to learn just as much from her as she was from me. And she changed my practice. I feel like I'm now much more willing and humbled to this understanding that I have to learn from every single person in front of me. I don't need to be the expert for other humans. They are their own expert, and I'm just bearing witness. And I have a whole toolbox that they don't have. I've been trained in medicine, and I can help them on certain things they can't help themselves with. But my job is to really listen to them.
Judson Howe Yeah, I read something you wrote recently about mistrust being a non-listed social determinant of health. That sounds like it relates to this.
Katherine Gergen Barnett Absolutely. Thank you for bringing this up. So the National Academy of Medicine really listed as one of the social determinants of health, medical mistrust. We think about housing insecurity, we think about food insecurity, economic insecurity, all those things. We now screen for social determinants of health when people come into our office. Across the board, you know, we don't, we have no judgment about how people appear, seem, all of that. It's really important, it's called the Thrive Screener. Boston Medical Center actually helped start this nationally. But we never ask about trust and how much do you trust the healthcare system. It's really a hard question to ask, right? Especially when you're the one, you know, as the ambassador for the healthcare system. But what we understand and why it's so important to kind of frame it as a social determinant of health, because all the other social determinants of health in the same way that mistrust is kind of framed, it's something outside of the biological system, which is going to impact your health outcomes. So if you don't have enough food, or if you're homeless, obviously, think about somebody who's got housing insecurity and has insulin they need to put in a fridge, that's going to impact their diabetes outcomes. In the same way, if you have mistrust of the medical system for very good reasons, there's lots of communities that do historical present day, we could spend all day talking about that. There's all kinds of data to show that people are less likely to come to the physician or a healthcare provider, even if they have the means. You know, we're so blessed. We live in Massachusetts. Almost everybody has health insurance, right? It's like MassHealth was the first to roll out here. You're less likely to come. And if you do come, you're less likely to share exactly what's going on with you. You may not actually give all of the information to your provider so they can really understand what's going on. And say you do give all that information and you come in, you are less likely to take the advice of a clinician. You could share all the information, get the diagnosis, maybe get a medication or some sort of treatment. And if you mistrust the system, you're going to say, well, thanks, but I'm actually going to listen to my neighbor. Part of the reason I became so interested in this and we actually wrote about this a lot during the pandemic is we realized, again, that neighbors have more influence over human beings than the health care system. So how do you actually work with the communities and the power of the community to build trust back up? And that's what I've been really interested in. Getting the wisdom of the community to drive some of the ways that the health care system has to change to say, you know what, this is what's not working for us. The way you report your data, or the way that you say you're going to do something and you never actually follow up. The way that you put a referral in, but nobody ever calls me. These are all the ways that mistrust builds and trust gets fractured again and again. So how do we make healthcare systems accountable and how do we make their data transparent? And how do we stay curious? It's going back to our initial conversation. How do we have healthcare providers stay curious and engaged with the person in front of them? Because it's only by staying curious and open that you actually maybe gain some trust from the person in front of you because you're asking the questions that actually most address what they're saying rather than the ticker tape of questions in your head that you were taught to say.
Judson Howe Let's invert this a little bit. Have you ever regretted the specialty that you went into? Or, no, no. Tell me a time when you did regret.
Katherine Gergen Barnett I think it's less about the specialty itself, and it's more about the ways in which the specialty exists within the system. I know it's true for my colleagues across many different specialties, but just an example from today when I was seeing patients. I have a patient who has this — not even my patient, was there for an acute visit — has very, very acute back pain. Young person, immobilized, and I've been trying to get this person an MRI. And it's now gotten to the point where health insurance is saying, well, we have to do a peer-to-peer consult, which for your listeners who you may know, it's basically saying this person not only needs a prior authorization to get their MRI, despite the fact that they've done all of the other required things, but I need to take my time out of my schedule to talk to another physician to process the MRI, right? And so I have that. At the same time, I have somebody on $1,000 a month GLP-1 who's just asking for a refill. And I'm like, how does this exist within the same session that I can't get somebody this acute thing that they need, and this other person is getting a medicine that's costing the healthcare system so much? So for me, it's more of the frustration of having a bird's eye view into the way in which the health care system has been so financially motivated that they're cutting corners where corners should not be cut and letting costs run rampant in places where there could be other opportunities to think about reducing costs. And I'm not saying GLP-1s is a perfect place to cut costs, because I know it's a really important medication. Again, we could talk all day about that. It's more thinking about being in a specialty where you see it all, and you don't have the tools to help your patients in the way you want to. It's like sort of fighting against a dragon sometimes.
Judson Howe Yeah. You said something earlier that I don't want to let us not come back to, and that is Yale and Harvard do not have family medicine residencies. I'm not trying to turn this into an infomercial for family medicine, but we've established that health is more than biomedical science. You mentioned that family medicine is a powerful tool for policymakers to reduce the cost of care and improve health for communities. And here we are sitting in New England, you know, man's greatest hospitals are here, right? So they say.
Katherine Gergen Barnett Or woman's. Yes.
Judson Howe WGH left the hospital. What is going on there?
Katherine Gergen Barnett So, well, I think, again, it goes back to the incentives and where are the incentives. I will say I just got an email from a colleague who's a family medicine doctor who said she's just getting her foot in the door at Yale. So there's hope for Yale and places like Yale. And I also have great, I have amazing colleagues at Harvard, and I have hope for a place like Harvard. But until our legislators say primary care is actually the engine that's going to change our health outcomes and puts their money where their mouth is, then I don't think institutions have the incentive to do it because they're going to get all of the money they need from procedures and from the specialists. But guess what? Specialists don't get patients until you have a strong primary care workforce, right? And so I think what people don't necessarily recognize who aren't on the front lines is that you have to have a strong primary care workforce to take care of all of the basic needs of human beings, but also to make sure that specialists are kept in business. We work together. And so to cut primary care at its knees by not giving us the resources and time and workforce and street cred that we need in terms of getting to train people at all institutions, irregardless of how hallowed the halls are, is really doing all of us a disservice.
Judson Howe Yeah. Is some of the stigma coming from the misconception that family medicine is really the modern GP, so the unboarded.
Katherine Gergen Barnett Yeah, it's like, it's sort of like embryonic delivery of medicine, right? It's like a medicine that hasn't been fully put into formation, right? So if a pulmonologist is a fully-fledged doctor and maybe a primary care physician is not, which is actually completely false. But that is the narrative that I think that needs to change. And I think part of it is, I work a lot with primary care policy across the country. I think it's on us and primary care to get our message really clear about what is our value. What's our value in terms of delivery of care, in terms of health outcomes? What's our value to communities? And how do we drive that value into policy? So I think the work is on us, but it's also, it has to be a two-way street.
Judson Howe Is there also an uncomfortable truth that there really are some lower-performing medical students that have disproportionately gone into family medicine?
Katherine Gergen Barnett I think that's absolutely true. And that's part of what creates the paradigm of like, oh, well, then that's the easier specialty, which is hilarious because we literally take care of every single thing there is. But I do think that residencies are getting more and more selective. And again, we have so many applicants that go into our residency at Boston Medical Center. But I think it's really, again, it's on us to make it alluring to medical students to say actually, this is a really great specialty. And, like, why wouldn't I want to go on to it, right? So you make sure that the physicians and clinicians that residents and medical students are watching and shadowing are not super burnt out and not running around trying to do prior authorizations.
Judson Howe So make the case for me. So I'm graduating with $350,000 of medical school debt. You're telling me I'm going to make one third, one quarter of some of the procedural specialists. I'm going to have an increasing rate of social drivers of health presenting themselves in my panel. This actually could be a misconception I have – then 20 years ago.
Katherine Gergen Barnett I was going to say, this is the opposite of an infomercial for family medicine.
Judson Howe Well, so make the case for me.
Katherine Gergen Barnett So the case is, we flip all that.
Judson Howe I can be an ortho for $1.2 million a year. Or I could make $300,000 in Northern California.
Katherine Gergen Barnett Look, I think it's, first of all, what's driving you to go into medicine? What part of it is driving you to go into medicine? But I will say that the way you're putting it right now, of course, it's very few people who would want to have more debt, less income, more stressors, right? The flip side, again, is it is this incredibly robust, rewarding, honestly, for me, like a calling that you have to have or not have. It's like you listen to your voice and what you need out of your path. And for me, family medicine is truly an incredible way to serve. But not everybody should — if we're going to put more medical debt on people, it should not have to be like either I'm serving or I'm going to get paid. It should be that if you're going to family medicine, your medical debt is forgiven. You have an amazing team around you doing all the social drivers of health. You have community health workers. In our clinic, we have pharmacists. We have social workers. We do have patient navigators. So all of those things should be part of your team. Nobody does it alone. Not in a good functioning primary care setting. So you need to know that if you're going into it. And so you're not drowning. But the system needs to meet people where they're at. And the only way to do that is to actually change the incentives for the provider.
Judson Howe Back in my days as an administrator, I noticed that there's a weird phenomenon. Here we are in the home of Paul Farmer, and we have this weird phenomenon where humanitarians and people of faith are traveling around the globe into really really challenging environments and practicing primary care. And I thank them for doing that, that's a very noble work to do. And yet I come from rural America, where there are times that it feels like our challenges are very similar — and I probably am misspeaking on this one — but maybe without comparing there's really big challenges in the United States as well. And yet there was a time I was short by 45 primary care doctors across the community of 200,000 people. And I noticed actually this negative infomercial that I just did, we went from recruiting on wine and redwood trees, which we do have and chasing good salaries and golf courses and places to live, to we actually started to pivot to what I mentioned. We have multi-generational poverty here. We have four times the national average of adverse childhood experiences. We started to go down to the missional purpose. And we started to find the humanitarian, FM's, primary care docs more broadly, I should say. And we started to build that stem. But you know what? For me, I found that as we shifted our attention to primary care, the specialists in the medical hierarchy pushed back really, really hard. Why would an administrator put so much time into primary care? Now, I will tell you, the economics lined up for us. Where we were, you mentioned incentives, right?
Katherine Gergen Barnett Yeah, you build your base.
Judson Howe We were actually paid to keep our Medicaid patients out of the hospital. That's how we made our money. And so we found the secret sauce is that FM and pediatricians is really the best tool we had. And yet, how do you get them into rural America? And so I share that as a, not to inject myself too much as a story, but here you are where we've got OBBB coming online — without going into too esoteric for the listeners — 340B coming up cuts, massive cuts coming in a couple months, work requirements coming online. So you're talking to the governor of Massachusetts here. What should she be doing? What should she be doing to prepare for that potential crisis? What is she doing? Or what are you telling her and how are you helping her?
Katherine Gergen Barnett So, again, I feel very lucky to be living in a state like Massachusetts. What we know is happening right now around the country is that every state is making their own decisions. We've learned a lot from the pandemic in terms of how you make yourself ready, for instance, for Medicaid cuts and specifically what happened with Medicaid churn after the pandemic relief was over and people came off of Medicaid and had to re-enroll. We got people out on the streets, we have community health workers we have yeah exactly
Judson Howe Re-enrollment was paused for a couple years, and then it was restarted.
Katherine Gergen Barnett Exactly. So the Medicaid rolls were really big and a lot of people had Medicaid. I wrote a whole op-ed on this, on a patient of mine who was doing so well and his diabetes and his hypertension and he fell off the rolls and I didn't, it wasn't even made clear to me. And he ended up having to go on dialysis. So now he's back on the rolls, but he literally ended up getting a transplant. So thinking about what are the costs literally to a patient's lives and to our system about what's going to be happening when people come off of Medicaid. And/or they need to go through these rigorous processes every six months to stay on Medicaid. And so how do you do language concordance? How do you make sure that you have people knocking on the doors? How do you have trusted messengers out in the community making sure that people know what to do. So again, Massachusetts, Governor Healy and her team, who again, I have the greatest respect for. And I know that they're thinking about this, because I've seen part of what their literature is that they're putting out. We are all getting ready. But again, I'm at a institution that is very largely Medicaid driven. So we're all bracing for this change. And inevitably, it's going to be a change, but primary care has to be at the base of what's going to keep us alive.
Judson Howe Now Massachusetts could keep funding Medicaid, correct? That's a budgetary choice they could make.
Katherine Gergen Barnett Yes. Correct. We will absolutely be hit like every other place.
Judson Howe So the state budget’s where the pinch point is going to be. I was talking to a colleague of mine who's in a Midwest state, and it happens to be a red state to use the term. And it's a small state. He's telling me that his Medicaid reimbursement is going to climb for the next five years because they weren't a Medicaid expansion state. And so my concern as an administrator on the coast is that the coastal states are going to have budgetary decisions that some other states are not going to have to make themselves. It feels like there's an intentionality to what we're going to have to go through.
Katherine Gergen Barnett Yeah. No comment. I mean, yeah, that's right. I don't want to end on the no comment, though.
Judson Howe We can edit it too um i went more like it becomes very political very quickly
Katherine Gergen Barnett I meant more like it becomes very political very quickly in terms of like who's going to be more hit.
Judson Howe Yeah. We had one guest say, giving Medicaid to somebody is not the same as giving them access to healthcare. And we sometimes confuse that on the policy side. How would you? I feel like we're at the inverse of that right now. Taking away Medicaid, we're associating that with taking away healthcare.
Katherine Gergen Barnett Let me go the way your guest talked about it, which is, yes, just because you have Medicaid doesn't mean that you actually have access to health care. Part of what we are talking about is the dearth of primary care, right? Which is like literally the front door for health care, right? Massachusetts is a state where you have to wait weeks to months to have a new primary care person. The Globe did a great set of articles on it, where it's impossible to find a new primary care physician in Massachusetts. So guess what? You have Medicaid? That doesn't mean that you're going to get to go see somebody who can care for you. On top of that, all the things we talked about with mistrust. Just because you have Medicaid doesn't necessarily mean that you will go. But also remembering all the things that go with Medicaid, which is specifically thinking about pediatrics. Pediatric health is largely driven by Medicaid. 20% of our deliveries or more in Massachusetts are covered by Medicaid. It's not just like a certain population that people might think of in their mind when they think of Medicaid. They really have to think about the ways in which it's going to hit people in SNFs, or ongoing care for people with disabilities are going to be impacted by Medicaid. I do think that the cuts are going to be a way of hopefully gathering people to understand what's most important to us to keep our population healthy and where can we focus our energies. But I am worried. And I think it's a time for revolutionary conversations with other people.
Judson Howe I have our next guest, and I haven't told you who that is, but give me a question to ask them on your behalf. Pass the microphone to them. What do you want to ask them?
Katherine Gergen Barnett Maybe what makes you most worried about the future of health care? And what's one thing that you've seen that's really moving that in the right direction?
Judson Howe So you've mentioned the role that mistrust plays in the delivery of healthcare, in your patient panels, in your practice, what are things that you're recommending to your residents to restore trust?
Katherine Gergen Barnett So I, as I shared, so much of the work that I've done on trust is driven by community members sharing with me what they've borne witness to. Or patients. And so for me, there's lots of different layers that need to be taken care of in order to truly build trust back into medicine. One is on the individual level, right? And so how can a clinician sit with complete curiosity and truly listen to their patient? I know one of your questions that you had sort of had in your mind is like, what would you get tattooed onto a medical student's scrubs or a resident's scrubs? And I think part of it is stay curious, right? Like how do you actually stay curious in the room so that you can truly see the person in front of you. The second is to name why somebody might mistrust, not assuming that they would, but to actually be versed enough in what a person's background, both their own background and historical reasons for mistrust. So, there are lots of ways to do that. But to actually say I understand that there are so many reasons why you might not trust being here, might not trust me, you're just meeting me for the first time. What can I do? What matters most to you? How can I meet you for who you really are, Judson? Rather than saying, what's the matter with you? saying, what matters to you? And actually having that be a key question you ask every patient and even having it as, Mr. Judson, it really matters that he stays healthy enough for his grandchildren so that every time you come in, I'm able to build on that. That's a relationship piece of trust. But then there's a system level approach. So we work with Massachusetts Health Quality Partners, so MHQP, and we did a large system analysis of ways to rebuild trust. One of the things that MHQP does historically is they send out surveys to every single person who comes in to see a healthcare provider that's part of the MHQP network, and five of their questions or more on their survey address trust. So we can actually analyze that data. How do you think on a systems level? How can we take that data and actually make it part of the patient experience? How do we say trust is part of measuring what matters, and we're going to pay people based on how well they build trust? We're going to pay providers, right? We know that patient experience score is part of the metrics that people are using or hospitals are using to pay providers. Trust should be a part of that. And then you're going out and you're thinking about, okay, how do we look at the research world, right? For instance, I do a lot of work on clinical trials. Part of what I'm talking about is how do we get people at the table to be engaged in clinical trials who historically would have mistrusted clinical trials for very good reason, people who feel like they were experimented upon or their grandmothers were experimented upon. How do you get people to be at the table for that? First of all, you talk about what the role of mistrust is. Second of all, you use patient advocates or people who have lived experience to be your ambassadors, to share why does it matter to be in a clinical trial? It matters because you want to be represented. You want your voice to be represented because we know that improves outcomes. We want you to have early access to medications. That's why you should be in a clinical trial. Part of what I was doing is making sure that young people who come from marginalized communities could be in clinical trials and feel really good about it. And then how do you actually build research studies driven by NIH, driven by others, that say community voice matters and not just a tokenism, but actually having community, whether they be boards or patient advocacy, driving what the questions are that are being asked in research. So it's not just oh, that's nice, you have a few community representatives. But saying, actually, you all are going to drive this research. That's called community-based participatory research, and it's actually a lot of what I do. It's super humbling and it's super important.
Judson Howe Humbling for you?
Katherine Gergen Barnett Humbling for the investigator, because usually investigators like a researcher like myself, who does lots of other things you want. This is my question, and this is how I'm going to collect the data. And guess what? When you're working with a community and they're driving the work, you say, what do you think about these questions? They're like, these questions stink. Then you have to go back to the drawing board. But it's like, okay, you're my teacher. How can we in science continue to use the community wisdom to teach us how to be better and more trustworthy? It's not on the patients, it's not their fault. It's our fault. We need to change medicine. We need to change medicine so we're more trustworthy.