Transforming Healthcare—It Needs It!

Image by Abul Hassan from Pixabay

The healthcare system has overstepped its bounds. That’s the thesis of this blog post. Healthcare promises health and it can’t deliver health. It may be successful in treating disease, but the determinants of health lie almost entirely outside the healthcare system. Families are responsible for health and communities are strong contributors. When healthcare tries to assume responsibility for health, it becomes intrusive, controlling, and condescending.

The inflation of healthcare can be seen in the change of mission of the CDC. CDC stood for the Communicable Disease Center when it opened July 1, 1946. On July 1, 1970 CDC came to stand for the Center for Disease Control with diseases that are non-infectious such as heart disease, diabetes, and cancer falling under its jurisdiction. Finally, on Oct. 14, 1992 CDC stood for the Centers for Disease Control and Prevention. In this final form CDC tasked itself with the health of Americans, including the prevention of diseases of all kinds including the prevention of alcoholism.

What follows is an approximate transcript of my interview with Dr. Daniel Hindman of the Johns Hopkins hospital system. Dr. Hindman thinks like an outsider who is embedded within a large hospital system. He asks big questions that few others are asking.

[00:03] Mike Gray: This season, I'm interviewing people who are telling their stories of transformative learning. Transformative learning is catalyzed when we are confronted with what's been called a disorienting dilemma. The collision happens when we have the courage to ask questions that may unseat our previous thinking. We all know that something is seriously wrong with the healthcare system in the United States. We spend more per person than any other country, and we've worse outcomes than many. Today's episode asks the big questions about the root causes of our dysfunction. My guest today is Daniel Hindman, a friend and a former student. And yes, those two things can both be true. He and his wife, Susannah, live in Baltimore, Maryland, along with their three children. Daniel's a physician with training in pediatrics and internal medicine, did his residency at Johns Hopkins, and later served on the faculty of the medical school there. Welcome to the program, Daniel.

[01:16] Daniel Hindman: Thanks for having me.

[01:18] Mike Gray: Been looking forward to it. We're talking about transformative learning this season. By that, I mean learning that's catalyzed by collisions with reality that motivate us to reevaluate our assumptions. And Daniel, as much as anyone I know, has embraced opportunities where such collisions are inevitable rather than shying away from them. You've always viewed these as opportunities to grow. What is it about your makeup that catalyzed these opportunities being embraced rather than avoided?

[02:01] Daniel Hindman: Yeah, no, I appreciate you starting with that question. So, I would say that I've kind of learned more about myself over the last few years in that regard than I maybe knew previously. One of the things I've come to realize about myself and the way I kind of look at things is that I like to ask really big questions and think about the issues behind the issues a lot of times. And so that kind of predisposes me towards what I've learned to call, though maybe this isn't the best phrasing for it—kind of more vision and mission type thinking or strategic planning or kind of what really motivates us for why we're doing what we're doing. And because of those bigger questions, and I think maybe just more experience having to confront them repeatedly. When I feel one come up, I just feel by virtue of kind of my education at this point, my mentality has been to look at it and turn towards it and say, I don't know the answer to this big question I'm asking, or I'm not sure I really understand what I want to understand here. So, I'm going to just dive into something I feel like I don't know the answer to and trust that on the other side of that is something better than what I'm doing right now or than what I know right now. And that's the best way I know how to put it. I actually was recently talking to a group of fellows and said, I think that my disposition is really weird and that I'm drawn to the things I know nothing about and that when I find something I don't know anything about, I'm like, I'm going to go do that thing. And that's how I've ended up in my current job now, which we'll talk about later. But I freely admit that's really weird. And I've just started leading with saying that I'm really weird. I can't explain that fully, but there is, I think, within that kind of this real deep enjoyment of learning and this comfort with risk taking when it comes to some of that. Yeah.

[03:57] Mike Gray: So how much of that do you think is just the way you're wired and how much of it has been, I guess, payoff from having that disposition?

[04:06] Daniel Hindman: Yeah, that's hard. I would rephrase that as kind of how much of that is nature versus nurture and I don't know. I think my guess is probably there's some of both. I did not feel as a kid like I was a big risk taker. I think there's still ways in which I'm not, but it's interesting in having your own kids, you see kind of traits of yourself that maybe you didn't notice when you were a kid. And one of my children, at least two of my children, are pretty big risk takers. And so maybe there was some of that in my childhood. But I think that it's easier for me to look back and see kind of the ways that I've grown in doing that over time. And I think for much of my educational experience, I was pretty comfortable because I could rely on kind of a natural giftedness in learning. The first thing that made me really uncomfortable in learning and putting into practice what I was learning was actually speech and debate in high school, where because it's in front of an audience and because it's happening in the moment, it's harder to retreat kind of into, at least for me, it was harder to retreat into kind of native skill and ability. And actually, some of my real seminal failures that I think about as being formative for future learning came through speech and debate in high school. And I've even told my kids about those, like I got to the final round of a debate once at a decently reputable regional debate tournament at a university, and just totally fell on my face in front of a room, probably of, like, 30 to 50 people. And that was really unsettling at the time. But I think I know that in retrospect, the reason I then went on to do other things and to be confident that it could be better and that I could still learn was because of that failure. And then when I got to residency and after medical school, the residency environment I was in was one that really cultivated autonomy and putting yourself out there, and one of the mantras that I came to really embrace was that it was the job of the intern to fail, by which we meant that your job was just to put yourself out there with your reasoning and be okay with the feedback that you got, because that's the way you would learn. And so being in that environment, that kind of crucible of failure and vulnerability, I think, helped shape, or I know, helped shape that tolerance for risk and also just the recognition that this can be a huge growth opportunity. And I say that, but at the same time, I would never want to live in residency all the time. It's of limited duration. But I think that that mentality and a certain tolerance for continuing in that mentality is something that I took with me beyond residency training and into fellowship and to faculty development and career as well.

[06:50] Mike Gray: Yeah. And since we all fail at times, it's a healthy disposition to view it as an opportunity for learning rather than to try and make excuses for why we failed that don't reckon with. It's an opportunity to learn in a variety of different ways, from dissecting the failure process but not living in it.

[07:16] Daniel Hindman: Yeah.

[07:18] Mike Gray: Let's kind of back up, because I think one of the places where I recognized your desire to become all that you could be was while you were in medical school. We had a little bit of contact after you moved back to the area to do your third and fourth years of medical school. When you took the Step exams in medical school, you approached them differently than many of your peers, I think. So, first of all, what are the Step exams?

[07:50] Daniel Hindman: Yeah. So the Step exams are basically the process by which you become certified with the National Board of Medical Examiners to eventually get into residency and go on and become a physician, you have to do the Step exams as part of your medical training. They're crucial to your application to residency, and you can't become fully licensed in a state until you've completed the step process. So, there's a series of three Step exams. At least I think there's still three. They've changed a little bit over time, and they're always shifting them. So, you have Step one and Step two that take place during medical school. And Step one is kind of more basic science oriented to the first couple of years of medical school, and then Step two is more kind of applying that basic science to clinical practice. So, when I was in medical school, and this is a little different than now, Step one was really the score that mattered, applying into residency. Now, what's happened is Step one, if I'm understanding it correctly, has become pass/fail. And so, the score doesn't matter so much. What really matters is your score in Step two. But when I was going through medical school, Step one was really the primary score that people saw when you applied to residency. The reason kind of I approached Step one differently during medical school was because I had been disappointed with how I performed on the MCAT. I had done practice tests, and I felt like I was in a pretty good place. But I didn't really have a strong game plan for preparing for the MCAT. I think I maybe just prepared for, like, a month before taking it or so, but didn't really have a method for how I was approaching it. And I knew I could do better than the score I got. I felt like that was a fair assessment of myself. It wasn't like I was sitting around with this attitude of, like, I'm better than this, and I'm going to prove it to the world. It was more just like, I don't think this really reflects my abilities. And so, when it came to preparing for Step one, I just decided, I'm going to take this much more methodically, and I am going to really try to prepare for it in advance because I want it to be what I feel like is a more accurate representation of my abilities academically. So, I ended up starting months in advance, just reviewing a little bit every day. I bought a Step one study guidebook. I bought another book by a professor named Golian. That's like a famous pathology professor and has a book. And then I think, if I recall correctly, I got some scholarship to have access to a question bank early on, so I didn't have to pay for it, which was a huge help. I started studying a little bit every day during medical school, usually trying to align somewhat with what we were studying in class anyway. And then I also started doing so many practice questions every day, maybe like ten practice questions a day. It depended on kind of how busy things were, what the goal was, I set for myself, and just really started methodically moving through the Q bank, and I actually finished out that Q bank that I got by scholarship. And then I paid for a second Q bank and started to do that Q bank afterwards, again with just this kind of slow, methodical approach that was really helpful for me, both in kind of knowing my approach to the test and how the questions worked and how to think through the answers, but also in terms of just really knowing the material and inculcating it, digesting it, and being able to apply it to the test in front of me, and then beyond that to the wards and to clinical practice.

[11:16] Mike Gray: So that's a different approach than most of your peers would have had, partly because the first two years of medical school, the basic science years, as they often referred to, are characterized as like drinking from a fire hose. So, you had all that going on, and then you're adding things to your own workload by pursuing these question banks. I'm sure you were as fatigued as anybody else, but you were motivated, you say, to try and make a score that would reflect better on what you were capable of doing. So why did you make that kind of sacrifice? And maybe related, why didn't many of your peers have the willingness to make the same sacrifice?

[12:08] Daniel Hindman: Yeah, I did start a little earlier than some of my peers. I remember a good friend, I tried to get to do some of it with me, and he had a hard time being able to carve out the time to do that on the front end. But there were other people that tried to do the same, and then some successfully did it. I understand what you mean by saying that I was so fatigued probably back then, but I look back then and I'm like, I had so much time compared to life now in residency, and maybe that's a little bit of a different perspective. On those first two years, I actually felt like, yes, medical school was busy and it was a fire hose at times, but it was the first time in my life where I didn't have to show up for class, where I could decide if I felt like I already knew something from my undergrad experience or if I could learn it better at home, on my own, than the lecturer was teaching in the classroom. I could make that call and be comfortable in it and adjust my schedule accordingly and maybe spend less time working on it on my own at home than I would have by going to class and having to spend time listening to a lecturer that wasn't communicating it well. And that wasn't true of many lecturers, but there were certainly some classes where I was like, I already really know this and it's not worth my time to go in and spend listening to this in lecture again. I'll just review the book and the slides and see what they're highlighting is important and then take and use that. I did have a different kind of more flexible approach to those first two years. I think that allowed for me to have the opportunity to kind of play with my schedule in a way that created opportunity to dedicate time to studying for Step one. My wife was also very understanding in helping me have that time and going through and doing it. But I don't know. I don't feel like I'm really answering your question, but I would say that in that space, in that time, it didn't feel like a huge sacrifice. It felt very consonant with what I was learning in the classroom. It felt like a good use of my time. It actually felt less stressful than I think if I put it off towards later. And it also, just as I did it more and more and studied and did more practice questions, it also felt really affirming in a way. It was like, I'm getting this. I have the hang of this again. When you're able to take what you're supposed to be learning in class and just dovetail that into your review for the Step exam as well, it didn't feel like they were competing with each other so much. It just felt like looking kind of what I said earlier, it felt like stepping back to look at the big picture and say, what's important in this moment? How do I keep the big picture and the vision in mind of what I'm really trying to accomplish?

[14:42] Mike Gray: Yes. With the big picture in mind, what potentially did a high score enable you to achieve that was maybe a potential payoff. And then I know that it did pay off. So, what was your mentality there?

[15:00] Daniel Hindman: Yeah, that was something I was least prepared for when things unfolded. So, I went into the test with really this desire just to do well. But then I ended up doing exceedingly well, and I had to step back and ask myself, what does this mean now for what? You know, I hadn't really gone into the test process with aspirations to apply to programs like Hopkins or Yale or Penn or Harvard. I just wanted to do well and for it to be a reflection of my knowledge and skill. But when I got my score and all of a sudden know that these avenues were open, that I hadn't really even considered up to that point, I tried to go around ask, know, how should I approach thinking about applying for residency? Should I aim for places like Hopkins or Harvard or Yale or these Ivy League schools or these upper tier residency programs? Or should I not make those a priority and make other values more important to me than maybe necessarily the reputation of the program? I think that's always the challenge. I think as I've gotten older, I've come to realize is that any choice you make is kind of a trade off in terms of figuring out the values that are important in that moment for that decision. And there's always going to be some regret involved in the choice you end up having to make because you'll miss out on something. For me, there were programs I was looking at at the same time that were very much more geared towards the underserved than the program I ended up at and that were more faith based, that were faith based and Christian programs that were appealing to me. And I honestly had felt like that was kind of the track I was on. And then I had this score, and it was like, okay, is it wrong to take this gift and use it to go to a place like Hopkins? Or do I feel called, do I want to value kind of more the opportunity to maybe learn in a certain faith-based environment, Christian environment? And how am I supposed to work this out now? So, it actually, for me, kind of posed this dilemma of how do I move forward and what is God calling me to? And how do I use wisdom to discern that?

[17:12] Mike Gray: But it definitely opened up avenues for you because you were not limiting yourself by your approach to something you did have some control over, and that is how well you prepared for the exam. You did take the opportunity at Hopkins. When you moved to Baltimore, you intentionally located in the inner city, and you still live there. I recall when I spoke at a convention there in the Inner Harbor, I took an Uber to your place, and the driver was noticeably uneasy about dropping me off on your street. He asked me several times if I was certain that this was the right address, and his parting words as I got out of the car were, be safe, my friend. Fortunately, I'd spent the night before at your place, so I knew wasn't perhaps matching the stereotype that you had at that part of the city. But what motivated you to live in the inner city?

[18:12] Daniel Hindman: Yeah. Before I answer that, I'll just say I have had that same experience where when my wife and I shared a car and I was in residency still, I would sometimes take an Uber home instead of taking the subway depending on the hour of night or day, and would have those same conversations with Uber drivers and have to tell them, like, no, I live here. I know where I am. I even once had a police officer stopped me when I was walking to the metro asking me, which is a subway, if I knew where I was. And I was like, I know absolutely where I am. Yeah. So, the motivation to live where we live in Baltimore during medical school, the summer after our first year of medical school, we went to work in Memphis for a month at this faith based Christian federally qualified health clinic, FPHC, that was started by a group of doctors who wanted to really serve a community in Memphis that did not have good access to primary care. When they did, people kind of thought they were crazy. But then it really took off. It became a series of clinics, and it still exists, a little different now than it was then. At the time, a lot of the doctors that worked in that clinic or group of clinics actually lived in the neighborhoods where the clinics were in Memphis, which were kind of areas very similar to where I live in Baltimore. And so my wife and I had this experience of being in a community that really sought to bring the gospel and a Christian view of the world to bear on some of the hardest places in Memphis in a way that didn't just kind of commute into those places, but made those places part of their daily lives, and that sought to address the health of the community by being part of the community and becoming really this integral part of it. And so that really moved us and really shaped us. It's one of the things that, in retrospect, we would say, we did say that there's some things, once you see them, you can't unsee. There's just no going. So, when we moved to Baltimore, the program that I ended up coming to here in Baltimore is actually a program that was focused and is still focused on urban health disparities. And so, my experience in Memphis really, I think, helped create a common language where they understood what I'd done in Memphis, because that was the program that they had here, similar, just without the faith based component. They really wanted to look at the health disparities that occur in the urban context, because I knew I was coming to a program that wanted to focus on health disparities in the city. My wife and I, we didn't really want to put ourselves in a situation where we weren't part of the community we were serving. And so, we chose to live in the type of neighborhood that many of my patients would come from. And to just make that part of our lives an imitation of what we'd been part of in Memphis. And one thing we learned in the past before moving to Baltimore, because we had done something similar to this, actually, when we moved back to Greenville, we chose to live in a part of Greenville that was under resourced, had a history of disinvestment. It was a neighborhood with a high amount of concentrated poverty, literally on the backside of country club, like the golf course. You could see it from our house. But it was this really kind of more racially segregated, impoverished community. And when we had done that in Greenville, it felt like we were living in a different city, even though my family was 20 minutes away. And that experience, which was great, gave us insight into realizing, like, this is really hard to do by yourself. And so, when we moved to Baltimore, one of the things we looked for was people who were already doing that in neighborhoods that fit the picture of what we were looking for. And we found a church where some people were doing that and ended up attending that church for a while and being part of it and participating with them in the work that they were doing in the community. We eventually moved a little bit up from the neighborhood we were first in to a similar community less than a mile away, and then also ended up going to a different church after a while. But the motivation was really to be part of a community that needed healing and that had experienced a history of disinvestment, the challenges of race and poverty, racial segregation and poverty in Baltimore that we knew we could contribute to. Whenever I talk about the story in my own community, I'm very careful in kind of the words, I should talk about this in part because of what I've seen people do when they try to come into my neighborhood now. So, it's important to say we didn't come in in any way with the intent that we were going to somehow save our neighborhood. I see this kind of thing still happening where people will move in and think they can save the neighborhood. Our approach really has been more to say, we're going to come and we're just going to bear witness and we're going to weep with you at some of what we see and what we experience. And sometimes that means literally sharing in people's weeping and being there for the hard things. It also has meant for us just asking the question of where can I bring the resources and skills I have to bear in a way that serves the community. It would be really easy to end up in a really nice, affluent community, but then not have our skill set, do much to actually serve that community. What's been fun and encouraging and a journey for us with where we live now is that without fully realizing it when we moved here, it provided this opportunity for us to really serve the community by bringing ourselves as a resource to the community through an attitude of service to say, what can we do to help, and how can you teach us to participate in the life of the community in ways that serve it?

[23:44] Mike Gray: You moved from maybe some idealism to some practical realities and are still motivated to be part of your community. I know after your residency now that you were able to practice medicine, but you instead took some low paying opportunities that were funded by fellowships and grants and decided to stay put. So, what motivated you to stay when effectively you could say, that was a chapter in our lives. We were here all the time during residency. We enjoyed the opportunities and now we're moving on. So, what motivated you to stay rather than practice medicine elsewhere?

[24:29] Daniel Hindman: I would say there were two things. So, one was Hopkins itself as a learning environment. There were things I still wanted to learn that I didn't feel like I knew yet. One of those was really learning how research happened and doing it myself. So, learning the methodology of it, learning how the data was crunched, learning how to take a hypothesis and really work it out through the research process into conclusions and with all the data collection and so forth. My fellowship was what's called a general internal medicine fellowship or an academic medicine fellowship, and it was really about three years of focused mentoring in research. But with that also I got a fully funded Master's in Public Health. That was the first eleven months of that. And so, it gave me this protected time in that to focus on learning public health and getting some credentials with it, which fit well with my life in the community and my work in the city. The second main reason was I had a chance to take a different job after residency and really came close to doing so. It wouldn't have been super high paying, but it was actually more in the public health sphere and the job was basically offered to me. But I ended up turning it down, literally because I walked out my door one day and was like, I just don't want to move. It was more just a sense of, I feel like we're supposed to stay in this place for now. And so that was more rooted in a sense of place and our neighbors and a commitment to our neighborhood, just that it wasn't the right time yet, that God was calling us to stay where we were and participate in the life of this particular community in this particular time.

[26:05] Mike Gray: In succeeding years, in 2020, at the outset of the COVID pandemic, you joined the medical school faculty at Johns Hopkins, and you also ended up managing the COVID response at one of the Hopkins associated hospitals. Is that a role that you chose—to manage the COVID response?

[26:29] Daniel Hindman: Give a little bit more detail to that in terms of what happened. So, I was in my final year of fellowship when the pandemic started. And because I'm trained as an internist and pediatrician, I was doing this fellowship that was focused on adult medicine. So, I had clinical experience with it to do adult primary care and some hospitalist work, but to keep up my pediatric skills that I developed during residency as well, I ended up doing a bunch of moonlighting at one of the pediatric ERs and inpatient units at a satellite hospital for Hopkins called Bayview. So, if you ever drive through Baltimore on 95, Bayview is actually the main Hopkins hospital you pass. It's just north of the city adjacent to 95, and has Johns Hopkins on it in big letters. This is totally an aside, but I have this really funny memory, actually, of driving through Baltimore during college and seeing that and being like, that looks like an interesting place. I'll never be there. And then I was. And so, during Fellowship, what happened was I was going into that night shift and had to figure out, how do we handle this situation? What are the protocols we're going to follow? And I was on with one of the lead PAs. Now, this is not like a big Peds area. It's a smaller Peds ER. It only has about five ER rooms, a dozen inpatient beds. There's a newborn nursery you're responsible for. There's a NICU, but that's run by a neonatologist. But again, coming in as the attending, that's really the main person of responsibility there. I was responsible that night for figuring out what to do. And so, the lead PA and I, we were good friends by that point because of the amount of moonlighting I'd done. We just sat down and we made up policies for the night that we knew were based on evidence and that were reasonable and that we could implement, and we had kind of the necessary supplies there to do. So then I ended up reaching out to my soon to be boss in Peds for my faculty position and let him know. Just like, hey, I just want you to know we made stuff up last night because it needed to happen. And if you need any further help with things, that maybe just let me know, because my research is pretty much dead at this point because it was more community based, and I can't do that because of the pandemic. I ended up getting a call from him either that day or the next. I think it was later, after I woke up from the night shift, and we talked and he said, hey, I want you just to come into the command center that's opening on Monday at the main children's center downtown, because we're probably going to use you to help out at Bayview. I said, okay, that's fine. And so, I went into the command center that following, you know, the chair of Peds is there for historical reasons. There's a chair of Peds at Hopkins Children's center downtown, but also there's a separate chair of Peds out of Bayview. And both of them were there. And I actually didn't know the chair of Peds at Bayview because she was new in her position. My about to be divisional chief in Peds took me into a room with this chair of Peds at Bayview. The three of us basically sat down and she looked at me and she goes, Eric tells me you can help and that you were on last night at Bayview. You have carte blanche. Just take care of it. It was like, oh. And so, we went through and discussed some of the politics of it and how to make sure know I could be empowered to do what I needed to do while also respecting other people's know. That week, I just ended up showing up in different places all around Bayview to meet with different administrators, whether in nursing or for the hospital or infection control, and started really trying to be as present as possible over there to run things while also still keeping up some of my adult medicine and fellowship responsibilities that needed to continue. And so, it was one of those learning experiences where I felt like it wasn't necessarily the thing I was looking for, it's just the thing that kind of dropped in my lap. I just ran with it in part because, as the chair told me, this is a pandemic. You just need to do what you need to do to take care of it. Just do what you know is best. I ended up being able to work with a really great team out there at Bayview and help run things and help guide the response and develop a really collaborative framework for doing so. I was able to develop strong relationships with my nursing colleagues and with my peers, many of whom I already had good relationships with. But it was a very different role to be building relationships in. And then when that had gone on for six to nine months or so. Eventually I was asked to consider being the medical director out there and took over that role with a team that I basically was able to build an assistant medical director and a director for the newborn nursery. All of us who wanted those roles were able to take them. And we looked at each other and we're like, we'll do this together and we want to do it together. That became really foundational to kind of my further development and learning because I started to realize like, I have an administrative skill set I didn't know about and that sense of vision and strategy and that love of kind of strategic thinking started to take root. I guess it already had roots. It just started to grow as it had opportunity to do so. So that started taking up more and more my time and it became a part of my faculty role and that I had funding for it while I still worked out there clinically. And then it just became something I really enjoyed, I really liked, and I really took pleasure in lots of things.

[31:32] Mike Gray: Everybody learned on the medical side of things for sure. During COVID to learn more about your particular gifting. Certainly, for somebody in leadership, big picture thinking is important. And flexibility in the middle of a pandemic and trying to decide what do we know now that we didn't know two weeks ago and how do we respond to that? Those are all good attributes in somebody who's leading. We might think, okay, so Daniel found his niche, but as I understand it, you no longer teach in the medical school. Instead, you're involved with the insurance program at Hopkins. So, what does the program consist of?

[32:20] Daniel Hindman: Yeah, so before I answer that, I'll kind of explain how that transition happened to provide maybe a helpful segue there. So, in my faculty role, by my own choosing, I had a very expansive set of, you know, I worked in this Peds area over at Bayview with about a quarter of my time. I'm sorry, I worked clinically with a quarter of my time. Another quarter of my time was dedicated to the administration of that area with a quarter of my time, which equaled one full day a week. I ran my adult primary care clinic where I saw adults out at a faculty practice in Baltimore, actually really in the suburb around no it was one day a week, but primary care that's set aside for one day a week is never contained to one day a week. They took up time every day of the week. I also did a half day of precepting medicine residents in their clinic downtown at the hospital. And then I had some more protected time from the Department of Medicine that I used for a variety of responsibilities, but I was also trying to keep up some research during this time. So, I developed and participated in some research partnerships and some work during those years as well. So, it became this balancing act where I was just working a ton. And again, nobody forced this on me. I kind of made it on my own. And so, I ended up working like 50 to 60 hours, a lot of weeks in ways that just weren't sustainable. And then I knew this wasn't really a long-term solution. The more it unfolded, though, I think also there were things that I developed this pathway before the pandemic really hit. And I think the pandemic really shaped it differently than I would have expected because of the impacts of the pandemic on healthcare and also just on me personally and kind of what I ended up doing in my job. So, as I was in that administrative role out of Bayview and discovering that I had this skill set I really didn't know about and was learning more from, one of the things that frustrated me was I just don't understand healthcare finance. I can run this unit and I feel like I'm doing a decent job, but at the end of the day, I have no clue whether we're making money and I have no clue how we're losing money if we are, which I assume we are, because Peds typically loses money in hospital revenue. And then on top of that, I just don't understand exactly how all the insurance issues relate to what I'm doing here and how the reimbursement works, what the pattern is. That stuff was never taught to me. I know insurance is out there and it pays for health care, but when it gets to the nuts and bolts of it, I don't really understand how it works in terms of my day-to-day work and I don't have the knowledge then to take and let that inform how I direct this unit and how I run it operationally. I knew that we were doing better on revenues than we had when I started, which was encouraging, but I still didn't understand all the nuts and bolts of it, like I said. And the more I asked questions, the more I realized I just didn't understand things. And so, in the fashion I described earlier, I eventually it was like, I don't understand this, I'm just going to go do it. Because I was like, the only way I'm going to really learn this well is if I just go work for a health insurer that's one way to do it. And then on top of that, there was this concern of, like, my kids are in a very different stage of life now, and I'm not getting time with them. And I feel like that's a problem with this particular stage, and I need to be with them more. So how can I find a job that allows me some more time with my family, maybe some more time in my community? And that also lets me understand healthcare, finance and insurance in some regard. And so, I ended up actually, before dinner one night with one of my kids in my lap, throwing in an application to a job I saw through LinkedIn, of all places, at Hopkins for a medical director role in their insurance arm. And we're a smaller regional insurer. We're not very big, but there were multiple lines of business. And as I looked at the description, I was like, you know, I'm pretty sure that I already know a lot of this, but I think the parts that I don't know, because this is Hopkins, they'll see my application. They'll say, he doesn't know this, but he's from Hopkins, he's from here. Like, we can teach them. And so that was kind of my hope, putting in the application. And that's exactly what they ended up saying to me. They're like, you have more than enough credentials to do this, and you have the experience you need for the most part, but the aspects of it, you don't know. We'll teach you, and we'll onboard you in, and we're fine doing that. And so, I ended up about a year ago now, coming on as one of the medical directors for what's now called Johns Hopkins health plans. And so, we run multiple insurance products, like, we administrate Hopkins employee health program. We also have a Tricare product for the Department of Defense that we help administrate. And then we run the state's largest Medicaid product, and then we have a Medicare Advantage plan. I help do all kinds of things with that. So, the main kind of thrust of my job is actually pretty mundane and sounds pretty boring, and that is that I review prior authorization and claims requests with part of my time. And that's not particularly exciting, but it has given me a very different window into the broader healthcare world than I had before. To see notes from places where you just kind of raise your eyebrow and you're like, how am I supposed to know what's going on from this to have to compare to kind of the experience I had at Hopkins? But then what I find more enjoyable and has more kind of been a course of professional development for me that's been very affirmed. The skill sets I bring from the school of medicine, the relationships I bring with me from the school of medicine that then take, I'm able to take and apply within the insurance environment at Hopkins. So I didn't really anticipate the breadth of skill I would be able to bring from my clinical experience and research and data experience into able to, because of my research training, I'm able to look at data, to analyze data, to write code for data analysis, and to really test data on my own, which as a medical director is a really unusual skill in an insurance company, particularly when it's like a large data set. And that's been a lot of fun because it's allowed me to create dialogues between the department I sit in and then the department that's more responsible for our data and to bring clinical expertise to bear on some of the broader data questions in insurance, where historically they maybe haven't had as much of a clinician insight and response. And then also I'm able to help. My goal, what I'm working towards with my boss right now, is that I'm actually able to help influence even how we think about data and our data capture and our data organization and how we look at that data as an insurer, to think about possible risky practices that are happening out there or bad care that members are getting, so that we can then address outliers both for positive care, like good results, and for bad care that's happening. But that's all that research and data background that I've been able to bring to bear that I would not have anticipated being able to do. The other thing I've been able to do is, because of my partnerships with the School of Medicine and having recently been on faculty, I have a credibility and a just relational network where I am not far removed from the school of medicine, which has historically been an issue for the insurance side. So, I'm able to email somebody, not as someone from Johns Hopkins health plans, but as a friend and former colleague, to say, like, hey, we're having this issue within the insurance. Can I pick your brain about a way for us to fix this and actually tell me what frustrates you about the way we're operating when you have patients that have our insurance product and let's find a solution to make it better for everybody, for you, for the patient, and for us. And one of the projects I've been working on right now has been a ton of fun with doing that because it just throws off everybody's expectations of what an insurer does. I'm able to come in and say, I want to fix this and make your life easier, and I want to make it better for the patient and better for us. There is a way we can do that, and people just. That's just not the way an insurer normally operates. Like insurers normally make for more bureaucracy, they'll try to cut through it, but the relationships and the experience and the knowledge of the clinical side and the data allows for me to facilitate dialogues that could have happened before I was here, but maybe wouldn't have happened as easily because there wasn't the relational component there or some of the experience. So yes, it is somewhat bureaucratic, but my motivation for being here and doing this right now is to learn more about healthcare. Healthcare finance, how an insurer works. I actually read most of a healthcare finance textbook when I started. That was something I set aside time for just to learn more about and then also just to see what are the skill sets I have that can again play more into that administrative skill set, into thinking in this big picture, this overall vision, how we think about strategic planning, strategic priorities, what it means to deliver health care to our members, and really to just make good care more possible and less hard to deliver. How can we make it less of an uphill fight? I've really enjoyed it and my boss has been super affirming and very encouraging, and my peers have as well. So, I really appreciated it.

[41:12] Mike Gray: So, from your window at Hopkins, maybe we'll finish today by addressing a few big picture ideas. Assuming your experience at Hopkins gives you some insight, what would you think? Is there a fundamental problem with the US healthcare system or is that simplistic?

[41:32] Daniel Hindman: I want to talk about this question more by asking you a question, actually, and that is, I want to ask you, what's your definition of health? I'm going to put you in the hot seat for a second.

[41:45] Mike Gray: Well, I would say it's related to wellness, as we typically use the term. To optimize wellness is to be successful in keeping somebody from needing more health care services.

[42:00] Daniel Hindman: Yeah, and I think that's the place a lot of people come back to, is trying to think about wellness. I'm putting you on the spot, so apologies for that, but I think the answer in itself and our struggle to define health is a fundamental problem with our healthcare system. I don't think we've actually wrestled sufficiently with the question of what is it that healthcare is supposed to deliver, like, what is health? And because we haven't sufficiently wrestled with that question, we're putting more and more burdens on a healthcare system to deliver something it was never intended or created to deliver.

[42:39] Mike Gray: So, are you saying that this idea of preventative medicine is like something that's been added on to the responsibility of the healthcare system?

[42:48] Daniel Hindman: So, I would say that preventative medicine. So, I'm going to back up a little bit. So, I think certainly some of what I'm going to say is going to sound a little heterodox in some ways, and it probably is. I think prevention is important, and I don't want to demean prevention in any sense. Like, as somebody who practices public health and as also somebody who organizes in a community and advocates for public health in my neighborhood and prevention, I think prevention is really important. I think the challenge becomes when what you do is you put on the healthcare system all the responsibility for prevention, and you make it that the healthcare system is the one basically responsible for the totality of what it means to be healthy in the world, when the reality is that as human beings, we live in communities that have tons of other factors that come into them that shape our health and our well-being and our tendency towards disease or towards staying healthy in that context. Right. And so, I think you see this kind of struggle even in things like housing, right? You'll read the slogan like, housing is health. And yes, housing is instrumental to health. Let me back up to it. A hospital should not be responsible for providing housing services primarily, right. That belongs to a different entity in society, and some might say the government, some might say private sector solutions, et cetera. So that's one end of the spectrum. Right? So, who's responsible for those kind of basic instrumental needs to help, whether that's housing or food or so forth. Is the hospital really the best place for doing that? And so, I think that is a really important challenge. I think the other important challenge is that is evidenced by me having asked this question to medical trainees over the years. So, I've done residency interviews on a number of occasions, and this actually became one of the questions I would ask applicants for residency just to see what they said. It bore very little bearing on whether they got in or not. It was just, I just wanted to know if they'd thought about it. But I asked a number of applicants, what is health? And these are people that have completed medical school. They're super bright. They've been invited to interview at a prestigious program. And I just started, over time to become more and more surprised by the evidence that people hadn't thought about it, that the more I asked it, the more it became clear that there hadn't really been a lot of substantive reflection on what health was. And that part of that, I think, is just due to the medical education curriculum. But also, even when I did ask the question and tried to provoke dialogue around it, it was rare to find somebody who was like, that's a great question, let's have a conversation about that. And when I did find those kinds of people, it was a really good conversation. But you would think that for somebody who's going to practice medicine, who wants to promote health, that there would be some reflection on what health is. But often what it reduced to was like, well, health is the maximization of my happiness. Health is kind of my ideal life, which I would say is a really underdeveloped sense of health. It's also just really unrealistic. That doesn't account for the reality of death and what it means to, if possible, have some kind of equanimity and approach to death that recognizes it just as part of our life in this world. And it doesn't take into consider with any nuance, just the realities that there are different stages of life where you're not going to be able to live up to the same potential that you did in a different stage. Right? And I don't just mean being old. When you enter parenting, what health may look like can be very different than when you were single and unmarried in terms of what you're capable of doing and how you're capable of taking care of yourself and your body. And so, my concern with kind of what's fundamentally flawed in our U.S. healthcare system is that I don't know if we're willfully ignorant, that maybe that's a little strong language. I just don't think we're really ready to grapple with that question. And what we've ended up doing is anything that we see as. Or my fear, I won't say this dogmatically, my fear is that what we've ended up doing is that anything we see as standing in the way of our value system, of self-actualization and autonomy and independence, we have heaped on the healthcare system as being responsible for fixing and for helping us to achieve this vision of what it means to have the American dream in a way that is just not sustainable. And that I think is probably more responsible for the unsustainability of our health care system than anything else. We just haven't come to grips with our humanity, its frailty, its vulnerability, its contingency, and we're using the healthcare system to address those things instead without being honest about it.

[47:51] Mike Gray: Yeah, so I have a couple of reactions to that actually.

[47:54] Daniel Hindman: I'm happy to have questions or contradictions or whatever.

[47:58] Mike Gray: I think things that are parallel. So as part of I'm on a Medicare Advantage plan and we have to have a yearly physical to be able to renew our prescriptions for the next year, of which I only have two. But the system allocates quite a bit of time for that physical. And fortunately, I don't have a lot of complications to my health at this point. So, we have good discussions, me and my physician, but he's kind of like, yeah, whatever you're doing, just keep on doing it kind of thing. But I've got these questions that I have to ask so I can say I did it. And I know what your answers are probably going to be. I don't have a problem meeting with him for 45 minutes or whatever is allocated. We have a good time, whether that's the best use of his time or not. I actually get rewarded in my Medicare Advantage plan if I have somebody come by the home and essentially duplicate the same thing that my physician does in the yearly physical, actually get paid $50 if I'll have somebody come and do that. So, all of those things are like giving you an outlet, an opportunity to talk about things. But if there really aren't problems, I try and monitor the things that I do, including weight and exercise and kinds of food I eat and so forth. And yet it's by the grace of God that I'm healthy at this point.

[49:34] Daniel Hindman: Can I interject for a moment? Sure. What's funny about that too, is the insurer and the provider then get to claim credit for your health.

[49:45] Mike Gray: Right.

[49:47] Daniel Hindman: There's this system where it says, okay, we must be doing the right thing. The reality is they're not responsible. A wit, right. I agree with you for where you're at with your health, but we want to think that somehow they are. And it's just like, no, that's part of the problem too. And it's just the other side of the coin of somehow thinking that they've created the health of Michael Gray. It doesn't make sense that they should get to claim benefit for that when they're really not. And the fact that somehow we think the system is responsible for that, again, I think is just a reflection of naivety and part of that misunderstanding of what health is and where it's really formed.

[50:28] Mike Gray: So, another reaction that I have has to do with end of life care, hospice. I've had three family members go through hospice and eventually pass away. All of them due to cancer. Have followed this on a personal level, but also somewhat on an institutional, national level, and know enough that it's become more common for people to pass away at home than in the hospital. And I think in some sense, that's people wresting control when they realize the outcome here is really not in doubt. It's just, what are the conditions going to be? And how's the experience of the person factor into all of this? We're voting that we don't want any last-minute heroics here, and we're ensuring that we don't have any because it's at home.

[51:22] Daniel Hindman: Yeah, I think hospice is a good example of trying to bring responsibility for health. It's going to sound weird to say, but I think responsibility for health back into the community and to kind of delegitimate the expertise of dying from the hospital. Know an author that I found helpful on some of this, and that's important to some of what I'm saying about health, is there's an author named Ivan Ilich who I'm not sure if you're familiar with or not. He's a philosopher who was actually formerly a catholic priest, I believe, who wrote a book back in the 70s called Medical Nemesis or the expropriation of health. I'm sorry. Actually, it's medical nemesis or limits to medicine, and it's about the expropriation of health. And what's interesting about Ilich's work is, though it was written in the 70’s I feel like nobody's actually really sufficiently responded to it that I'm aware of. But one of the main critique is that when you take health and you make it this commodity of an expert class, and you attach dollar values to certain services for health, what you do is you devalue the kind of commonplace health care that happens in the community, expropriate health from the community by creating this separate class of what health really is that's attached more to monetary dollars or, sorry, monetary values and dollars and cents. Right? Because the things you can pay for. Oh, that must be the real health, right? Like, that's the health that actually has value. And he does this with several different domains. He does it with transportation and education, but then he does it with healthcare, too. And he talks about this reality of the expropriation of health often leads to people paying for things that aren't actually even healthy, you just look at the history of tonsilectomies, for instance. So with hospice, hospice allows for what has historically been kind of more a communal form of health care to take place again in the community. And that is the care for the loved one who's dying. That honestly doesn't require a ton of expertise. Right. And I say that in the sense that dying is clearly one of the hardest things any of us passes through. Right. I mean, it is really challenging, right. To face death and to have to go through the process of dying with all its pain and fears and questions. Right. What is provided in that moment, I think that would matter to most people, is not the bells and whistles of an ICU or the expert care of somebody who knows how to dose the morphine perfectly. Right? There's some knowledge that matters, but I think what matters to most people in that moment is love. Right? And so, to be with people who love them and to be close to them in this moment of really intense suffering, hospice allows for that to happen, and it puts that back in the hands of the community. Another really great piece of writing that's been helpful for me on this is Wendell Berry's essay, Health is Membership. Right? So, Wendell Berry is not a physician or a doctor or anything like that. He's a farmer and a philosopher and a writer. But his essay Health is Membership really talks, too, about kind of the mechanized, industrialized world of medicine that is supposedly meant to improve healing, but then the world of love, that is somebody's home and community and how integral that actually is to true healing and yet undervalued by the healthcare system. So, I think hospice is a great example.

[54:56] Mike Gray: Yeah. And a book that was influential to me was Atul Gwande's Being Mortal.

[55:03] Daniel Hindman: Yeah.

[55:03] Mike Gray: I've actually passed that along to several people who are facing the same kind of situation within their family, because if you've read the book, Gwande had to come face to face with it himself. I think it was his dad who was a physician. Like, they were onto the all hands on deck mode, and it wasn't going to get his dad any more life expectancy, but it was going to trash his quality of the remaining days and what he wanted to spend his time doing, the people he wanted to spend his time with. But, yeah, I think that kind of thing rings true on a lot of different levels. So, what I'm hearing is it's not so much the definition of what it means to be healthy, but it's whose responsibility is it that you are healthy or how to address it if you're not.

[56:00] Daniel Hindman: Yes, I think that is absolutely true. I say that sometimes in conversation that it's really a question of where is health formed? I do think the definition of health matters because in a society that values individuality and autonomy and has a certain vision of what the good life is, that is rooted, in my opinion, in a consumerist mentality, too, that if you can sell something as health, you can get people to spend money on it. And so, I think that plays into things in an important way, because people really think they can buy health. And there's a certain extent to which that is true, right? In that if you live in a certain community, you have access to certain privileges. But there's also a sense in which it becomes counterproductive really quickly, too, because things you think you are buying for health may actually not be health at all. So anyway, all that to say, the definition matters, but absolutely, yes, it's about where is health formed? One of the critiques sometimes levied against the healthcare system is that it's really a system that's better at disease than at health. And I actually think that rather than that being a critique, it kind of needs to be turned on its head and said like, yeah, you're right, and that's what it was created to do. It was made to manage disease, and that's what it's actually good at. So, let's let it be good at that. And then socially, as a society, we need to reassess kind of how we approach our responsibility for each other and for our communities and what that means for health formation and forming healthy individuals. Healthy communities. Berry, in his essay on Health is Membership. The whole reason he says health is membership is because he argues that the smallest unit of health is the community, which he defines as a place and all its creatures, that it actually makes very little sense to talk of a healthy individual, because the line between the individual and the environment and the individual's community is so thin. We were talking about works of literature, and you mentioned Atul Gwande, and it made me think of When Breath Becomes Air as well. I'm not sure if you're familiar with that one, but the whole idea of When Breath Becomes Air kind of gets to Barry's point. At what point is it just air, and at what point is it what I'm breathing? If the line between me and the community, the place I live, is as thin as a breath, then I really need to rethink what it means for me to be healthy. If the air that I'm breathing in the environment I live is an essential component of my health. To be healthy requires something bigger than just my individual person.

[58:36] Mike Gray: Right. Yeah. Very complicated and wide ranging in terms of responsibility and who can take actions to make things better or worse.

[58:49] Daniel Hindman: Yeah. I don't know how long you want to talk, but I think, actually, if I can make a little plea for a theological understanding here, I think that Christians are actually really well equipped for this view of health. They just often don't realize know whether it's your responsibility of caring for your neighbor or whether it's just an understanding of the world and the relationship between man and the earth. You know, when God makes Adam, he makes him from the dust, which is the soil. It is the earth. And man, as a being, is a participant within the broader world. He's a body within the body of the world. Right. And so, this actually makes very much intuitive sense from a Christian framing of the world. We cannot think of ourselves as somehow islands unto ourselves, like John Donne says. Right. That we are a piece of the whole and just. Even the image of Eve being separated from Adam again gets to you know that there is a single greater body of humanity within which I am a body. And then there is the body of humanity, which participates in the body of the world. And it also gets back to the idea that Christ, as a renewed Adam, has the church made as a new Eve from his side. But then it also anticipates the fact that with that, there has to be an entire new creation, too. That is a new earth that is consonant, just as the first earth was with Adam, with a renewed Adam and a renewed humanity, that we don't lose that basic aspect of what it means to be human, that we are participants in this broader body, whether that's the church, the renewed people, or the renewed heavens and earth. And I think if we were able to capture that vision more and the responsibility that comes with it and the beauty of it, it would be helpful in thinking about many things related to health.

[01:00:45] Mike Gray: Well, thank you for sharing your expertise and for asking those big questions that other people aren't asking and gaining the kind of expertise that is multifactorial, that leads to more insight. Thanks for being with us today, Daniel.

[01:01:05] Daniel Hindman: Thanks for having me.

[01:01:10] Mike Gray: Join me in two weeks for another stimulating conversation, this time with Daniel Hindman’s wife, Susanna. We'll be talking about collisions in her life between her ideals and her identity, as well as her struggles with reconciling mission and motherhood. See you then.

Recommended resources:

Being Mortal by Atul Gwande

“Health is Membership” by Wendell Berry (free pdf)

Medical Nemesis by Ivan Illich
"The medical establishment has become a major threat to health."

When Breath Becomes Air by Paul Kalanithi