Season 1: Episode 6 – Too Little, Too Late: Practicing Medicine at a Rural Hospital

Dear Healthcare It’s You: Episode 6

Elisha Yaghmai

One thing that happened. I'll never forget this. I had a guy come in to do to do a coverage for me on a weekend, right?

Jo O’Hanlon

Yeah.

Elisha Yaghmai

Over that weekend, he killed two of my patients. Straight up. Yeah. You just became in mismanage them. I came back and they were dead. Right. One of the guys that I. One of the guys. I mean, I came in to get silence. Sign out from him.

Jo O’Hanlon

Yeah.

Elisha Yaghmai

On Sunday night. And he said, yeah, You know, this gentleman's been here. You know, he's real sleepy. He's real sleepy. Obviously, I'm coming. Had wake up, you know, And I'm like, okay, what's that like? How long has he been asleep? since, you know, Friday. I said I'm. I'm sorry. What? You know, he was. The guy's been asleep since Friday, like, what have you.

Elisha Yaghmai

What have you done? no. You know, he's just real sleepy. You know, we just I think it was a urinary tract infection. I think that's what's going on.

Jo O’Hanlon

You know? But he was an admitted patients.

Elisha Yaghmai

So, meditation. Yeah. And I'm like, you think he has a urinary tract infection, but he's been unresponsive since Friday. It's now Sunday night.

Jo O’Hanlon

Welcome back to Dear Health Care. It's you. Welcome back to the podcast. Elijah Agwai here with us from Free State Health Care in Wichita, Kansas. My name is Joe Hanlon. Thanks for being here, Elijah. Where we've been going is talking about your medical journey. And last we left off with you about to enter the real world as a real world doctor.

Jo O’Hanlon

And you mentioned that you ended up starting out your doctor ship. Or how do you what is the proper phrasing of that?

Elisha Yaghmai

Typically you become you become a quote unquote, attending physician.

Jo O’Hanlon

Attending physician. Is that what you remain forever?

Elisha Yaghmai

Yeah, that's right. There is different terms in different countries, but in the US, basically you're a medical student and you're a resident. Yeah, you could become a fellow after that, which is another level of training if you do additional training beyond your residency. And then once you're done, done with whatever you're going to do, you become an attending physician, which means you're basically at the end of your at least at the formal education part of your journey.

Jo O’Hanlon

Okay. Yeah. So as an attending physician, you're starting off in Parsons, Kansas. That's where I'm currently. Yeah, that's right. And where is that?

Elisha Yaghmai

It's in rural Kansas. It's in southeast.

Jo O’Hanlon

Kansas. Southeast? How small of a town are we talking? You know, I.

Elisha Yaghmai

Can't remember the population. They have.

Jo O’Hanlon

Like, is there a.

Elisha Yaghmai

Line? Something like there is a Walmart. There is. There is a Walmart.

Jo O’Hanlon

Yes. No Target.

Elisha Yaghmai

There's no Target.

Jo O’Hanlon

Starbucks.

Elisha Yaghmai

There. There is a Walmart. And there was like a main strip downtown. And there might have been a little bit more, but it wasn't a huge town.

Jo O’Hanlon

Did it have high schools like infrastructure?

Elisha Yaghmai

And I mean, they had some schools. Yeah, Yeah. But it was, you know, I can't I don't recall it because I more or less lived at the hospital right there. But it was pretty it was a relatively small town. Yeah. They had some amenities, but not very many. There were a couple of fast food restaurants, right? There were some stores and shops.

Elisha Yaghmai

There was a Walmart that was kind of a dominant retailer for almost everything. Yeah. And then and then there was a hospital.

Jo O’Hanlon

And I want to ask because we haven't really talked about your personal life very much in the midst of this journey. But obviously that's a factor. Everybody has their stuff that's going on outside of school and now it's outside of your work. But this is a point in a lot to a lot of doctors. Journeys is having to move somewhere random.

Jo O’Hanlon

Right? And so can you talk a little bit about that of like were you married at the time I was with kids or one child? One child. What was that combo like? Was that expected? Like, I know we'll have to go move somewhere.

Elisha Yaghmai

Yeah.

Jo O’Hanlon

At some.

Elisha Yaghmai

Point. So what had happened actually was my my wife is also a physician. okay. And so we had gotten married midway through the fourth year of medical school.

Jo O’Hanlon

Four years in the same year.

Elisha Yaghmai

We were in the same year. Yeah. Yeah. And we had we had our first child shortly before about a little at that point, he was trying to think about what year this was. So he was a pro he's approaching two years old at that point. And so, you know, we had my wife had finished residency before I did.

Elisha Yaghmai

So she had been out working while I finished my residency in Wichita. In Wichita? That's correct. Yeah. And then I while I was finishing, she was applying to fellowship programs, had been accepted to a fellowship program up in the Northwest. And so we knew that we were ultimately going to be going there. But there was this gap of time between when I finished because I finished a little bit off cycle because I changed residencies.

Elisha Yaghmai

So it was a little bit of credit this last round a little longer. I didn't do the full five years, I did four years and and several months. Right, right. So I finished a little early. So there was this gap. And so, you know, in choosing what to do at that point, you know, I opted to go out to work in rural Kansas to to gain experience and then also just to have the experience of working rural.

Jo O’Hanlon

And remind me you'd been with a family practice before that. But that was all still that none of that was in rural areas.

Elisha Yaghmai

That was all that was residency training. Yeah. So I came in, did one year of family medicine before switching to medicine pediatrics, which is a different residency. It's a four year. So Family medicine is a three year program, right? Internal medicine or med Pedes, as we colloquially call it, is a four year program. Right. So I did the one year family med then I did almost another full four years impedes right and then finished up my my program there so that when I was doing internal medicine and.

Jo O’Hanlon

Pediatrics but but was this your first time in a rural setting.

Elisha Yaghmai

For more or less I mean, I got to do so. So you could do something called Moonlighting in residency, which is where you go. You have your residency job, right? That's the main thing. And then you can go out to other places to work on the side. I actually did quite a bit of moonlighting. So you can get you can get your medical license after you pass certain tests and then you can go out and work in a moonlighting capacity while you're still a trainee.

Elisha Yaghmai

And people do that for two reasons really. One is to gain experience and the other is because usually they're broke, right?

Jo O’Hanlon

Because it's actually being paid, rather.

Elisha Yaghmai

It's paid work rate. And so you get you have you get some extra money and then you also gain professional experience. So I worked all over. I went out into some rural communities, I worked in urgent care, I worked in the neonatal ICU, I worked anywhere I could work really to try to gain professional experience because there are just there are things that you encountered going on in the real world of medicine that you really didn't see in a training environment.

Elisha Yaghmai

At least I could speak only from my own training environment. We didn't see it in there, but we would see it when we went out into these other places.

Jo O’Hanlon

Yeah. And so you were growing, going, going kind of nonstop throughout all of medical school, which sounds like it's always the case pretty much for people who largely.

Elisha Yaghmai

Yeah, I mean, so this was the residency. But yeah, I mean some people in some some residents only do residency. Like that's all they do for some of them are restricted by, you know, immigration rules and things like that. Others just choose not to do any moonlighting. Right. But then others of us chose to do both. So we do a residency work and then we do moonlighting on top of it.

Jo O’Hanlon

Right. So then when you now you've become an attending physician here in Parsons, what was that like? You were at a hospital as.

Elisha Yaghmai

A I was a hospitalist.

Jo O’Hanlon

Hospitalist. Okay. So does that mean that you work in just like the pediatrics department or also.

Elisha Yaghmai

All of basically so that that hospital at that time had a hospital floor and then an ICU? Okay. Right. And so my job was to be responsible for the hospital. Anybody on the hospital floor, which is nearly always an adult, they had it. They had occasional pediatric patients, but I think they'd had a local pediatrician would come and do those.

Elisha Yaghmai

And it's protocol correctly, but basically was adult patients that were coming in. And then on certain weekends I'd also do the ICU. Okay. Another doctor at that time that was covering the ICU, I would fill in periodically when she was off and cover that as well.

Jo O’Hanlon

But yeah, yeah. And so what are those shifts like? Is it like a few days a week, five days a week?

Elisha Yaghmai

Know I was on basically outside of weekends when I was off. I was there every single day.

Jo O’Hanlon

For 12 hour shifts.

Elisha Yaghmai

Yeah. 77 was typical. Yeah. And you get called at night for admission sometimes and things like that as well.

Jo O’Hanlon

Gotcha. And that's kind of just about the job. That's not about you being new, right?

Elisha Yaghmai

No, no, no. That was the job at the time is basically they needed staffing, right? Yeah. So I was filling in, you know, covering days and nights and just doing the whole thing. As one chef.

Jo O’Hanlon

Gadget. And you mentioned before, really, really liking your time. I forget right at the moment if it was during your residency or during your fourth year. I'm sorry, your third year, but at the doctor's office where you just left for.

Elisha Yaghmai

Your fourth year of medical.

Jo O’Hanlon

Yeah, yeah, yeah. And so, I mean, was that a similar joy of being on your own, being in charge of your own profession in that way in a hospital?

Elisha Yaghmai

So it was a strange my, my experience, I think in I would say my experience in medical training was sort of I don't I don't know if was unusual or not. Right. I can't compare to everybody that did it. I can only speak for myself going through the early part of medical training, I did not appreciate how invasive medicine was.

Elisha Yaghmai

As best way I can describe it. Medicine as a discipline is very invasive in that there's a massive amount of information now. It is always increasing. There's always new research coming out. Right. And to gain skill at it, there is a point at which you essentially have to take most of the rest of your life and kind of put it on a shelf and say, I'm not going to really pay any attention to this for a while.

Elisha Yaghmai

All my other previous interests, hobbies, all the other things I used to read, Right, Right. So that's on the shelf. And I'm just going have to focus on this one thing, right? You know, for people that that like sports, I would put up the analogy of, you know, it's like the Kobe Bryant, I'm going to do 2000 shots a day every single day, right?

Elisha Yaghmai

I'm going to the gym at 4 a.m. and I'm a stay there for however long it takes to put up my 2000 shots and I'm to do my drills and I'm just going to do this every single day indefinitely, Right? Because that is what's required for me to be the best at this that I can be.

Jo O’Hanlon

Right? I it's not like the 10000 hours.

Elisha Yaghmai

It's not all it's worth. Yeah, it's more than 10,000.

Jo O’Hanlon

Yeah.

Elisha Yaghmai

And you you have to do this at at some juncture in your training, whether you do it earlier or later or the whole time, you know, it probably varies from person to person, but you have to do this. Residency was the time in my progression that this really happened, that I was like, okay, I'm not going to try to do all this on this.

Elisha Yaghmai

I had a fairly diverse series of interests all the way high school, college, even medical school. There was that point where I was like, This is the thing and I'm just going to need to do this. Yeah. So all I did basically was work.

Jo O’Hanlon

Yeah.

Elisha Yaghmai

Read about medical topics, read new papers, work some more, try to learn procedures. Right. And that was just that was basically the thing all around the clock every single day.

Jo O’Hanlon

That it.

Elisha Yaghmai

Was on.

Jo O’Hanlon

It was your wife being a physician. Also, you were able to kind of like go back and forth and talk about things. Yeah. Have that be part of your home life kind of cadence.

Elisha Yaghmai

It also I think it also helped because I think it's it's difficult for a non physician. I think other fields probably have a similar requirement, right. Yeah. But for a non-physician to understand that, you know, you're going to have to put in the 14, 15 hours of the hospital. Right. And then you're going to spend more time reading right.

Elisha Yaghmai

And you're not going to be around for everything. Yeah.

Jo O’Hanlon

You know, tolerance for one another because you're needing tolerance for each other, like for yourself.

Elisha Yaghmai

You have to understand that, you know, just the basic right. Because a lot of a lot of physicians that get married to non physician, well, in general, physicians get divorced fairly. I don't know. Do they have a physics. Yeah. Yeah. It's not it's not like I had I had classmates that got divorced during medical school. Yeah. You know, such high demand.

Jo O’Hanlon

Yeah, they're. They're gone.

Elisha Yaghmai

They're gone. These people were married to non physicians. And, you know, again, I'm not commenting on their religion. There were all the reasons, right? I wasn't privy to it, but. But it's a lot of stress.

Jo O’Hanlon

Yeah.

Elisha Yaghmai

This, this person is gone. You know, the training is their main priority a lot of the time. And some people understand that and some people don't like they they're just not content to be like, hey, you know, you're just going to kind of not be here for the next three, four or five years. You know, I'll just sort of.

Jo O’Hanlon

Wait around all.

Elisha Yaghmai

The time.

Jo O’Hanlon

On the have.

Elisha Yaghmai

Nots. But yeah, you know, I'll be here with the kid, you know what I mean? To be here and you just sort of show up and you show up? Yeah. Not everyone's good with that. So having at least some level of professional understanding of getting right what this is and what it requires.

Jo O’Hanlon

Yeah, I imagine that was a huge support honestly. So yeah, more than is easy to see from the outside of having not gone through that. But yeah, having someone who understands that level of like and then be able to be on the same page of That's my one hobby right now also, isn't it. It's like you both only have one.

Elisha Yaghmai

Yeah.

Jo O’Hanlon

Yeah, yeah, yeah. Well, so then what was the transition like moving into this role in the hospital and Parsons? I mean, so was it totally different? Was it didn't feel familiar? Did it feel good? What was it like?

Elisha Yaghmai

No, it was. I mean, so that I think I would describe it as that was sort of the pay, Right. Yeah. Because the part was I had done all of this work trying to learn all the, you know, I would come in really early. I would come in early in residency to get the hardest patients. So I would do this intentionally, right?

Elisha Yaghmai

I would try to get up as early as possible so I could come in, so I could get first pick of the patients. And my goal was to pick first. I wanted to pick because whoever got there first got the first sign out, right? So I would try to get there as early as I could to try to take the hardest patients.

Elisha Yaghmai

I wanted the most complicated and difficult patients.

Jo O’Hanlon

There were.

Elisha Yaghmai

Yeah, right. I'm on my service. Right? This is the this is the thing, you know, And I'm.

Jo O’Hanlon

Not I.

Elisha Yaghmai

Mean.

Jo O’Hanlon

If you're burning the candle at both ends, it's hard to be like, Yeah, I'll choose. Yeah. Be like, I mean, how that's pretty wise for your young self, But that's.

Elisha Yaghmai

The problem you have, right? Is that the more you do it, you realize that you have to do this right? Because. Because medicine is the analogy I've often used is it's like it's like water washing over rocks. Right? And you have to you have to encounter it even once, pick a pick a diagnosis, you have to encounter it, then you have to encounter it again.

Elisha Yaghmai

You have to encounter it again and again and again and again. And you have to keep doing this because the whole time what you're doing is you're burning patterns into your right, right. This is what you're doing. And so you need to see first, you need to just figure out the drop that obvious common diagnosis. Right? Right. Like, what is just blatantly obvious with this is first you have to get that right.

Elisha Yaghmai

And you're trying to do that through the early part of training. But then you have to get well. What happens when that common diagnosis comes in? But it doesn't look like it normally looks right. It looks different from normal. Right.

Jo O’Hanlon

Can you give an example of that?

Elisha Yaghmai

So I'm trying, you know.

Jo O’Hanlon

Yeah.

Elisha Yaghmai

I mean, it's it's what's an easy. Okay. So a simple one would be, you know, somebody comes in with heart failure, but it looks like pneumonia.

Jo O’Hanlon

yeah.

Elisha Yaghmai

Yeah. So the initial person seeing themselves on admitting this pneumonia to you. Right.

Jo O’Hanlon

Okay.

Elisha Yaghmai

And then you go in and say.

Jo O’Hanlon

Yeah, this doesn't.

Elisha Yaghmai

You know, it's not exactly pneumonia. Right? You know, they don't have any history of heart problems, but I just don't think this is pneumonia. Right. I think this is something else,

Jo O’Hanlon

Right.

Elisha Yaghmai

And then that has to trigger.

Jo O’Hanlon

Indications that you're seeing in their file or in the.

Elisha Yaghmai

Looking at you're looking at their vital signs. You get their history from them. Right. You you look at their lab studies. Right. And you just say the easiest way to describe it is I put it this way, the kind of mental process that goes on is you get fed pieces of information, right? So let's just say we'll do the typical with e.r.

Elisha Yaghmai

Calls you up. This is from the hospital perspective. E.R. calls you up and says, I've got so-and-so down here. At this age, they have these problems. And I think the diagnosis is this. They need to be in the hospital.

Jo O’Hanlon

Yeah.

Elisha Yaghmai

So you go through first. Do they really need the hospital or not? That's a different discussion. Right? Let's assume they do then. Then you're. You're you're taking in that information. You're taking in their vitals, their history, their lab data, their imaging studies studies. Typically that and then you're, you're mentally sort of, how can I put it? You're you're there are different diagnoses that are suggested by the story.

Jo O’Hanlon

Yeah.

Elisha Yaghmai

And then mentally you're you're sort of ranking them. Right. And sometimes, you know, but things that are equally ranked right, then you need to do more testing. Right? But you're kind of moving up and down on a probability chart. It's I mean, it's not it's not a formal probability. It is an informal probability chart. So you're saying what's more likely?

Elisha Yaghmai

What's next? Most likely. What's next? Most likely. Right. And in medicine, we call this a differential diagnosis, right? What's the list of things that could cause this symptom? But many of them are rare. You look at them, you're like, that's definitely not right. Toss that one. You're like.

Jo O’Hanlon

Starting with the whole Web M.D. list. Yes.

Elisha Yaghmai

That's right.

Jo O’Hanlon

I haven't had. So you're done.

Elisha Yaghmai

Exactly. Yes. So if you ever had a you know, could be a brain tumor or, you know, there's a long list of other things. So you do that. And so that's the you're working through that process of of stratifying things and sort of ruling things in or out. Right. But but to, you know, so so for example, they could call you and say it's a pneumonia, right?

Elisha Yaghmai

And then you go say, well, you know, what's the story here? Right. Well, what's your story? Patient Right. You know, and they tell you a story and you listen to it, you know, and you say, that's not exactly that's not a great pneumonia story. You know, it's a better heart failure story.

Jo O’Hanlon

Like there's something in the stuff that's telling their story.

Elisha Yaghmai

I mean, I could outline specifics for you, but, you know.

Jo O’Hanlon

Right. Yeah.

Elisha Yaghmai

The technical detail. Right. But it's you know, they do that. And then you look at the labs and the labs don't exactly jive. And you look at the you look at the imaging and the imaging doesn't exactly jive. Right. Right. These things together. And so you say, okay, here's a situation where it was heart failure, common to diagnosis.

Elisha Yaghmai

Yes. Right.

Jo O’Hanlon

Yeah.

Elisha Yaghmai

But it came in looking a little bit different this time. Is pneumonia a common diagnosis? It also is. Right. Right. But again, it's not exactly fitting. So my point is that you see you see kind of the way we describe it, there's common presentations of common diagnoses, right? That's statistically what you see most of the time. Then there's uncommon presentations of common diagnoses.

Elisha Yaghmai

Right? Right. And then you get to uncommon diagnoses. Right? Right. And then you get to the super rare, you know, one in a million stuff that usually takes a while to get to because you have to work through all the other stuff first before you get there. But the point is that you that medicine is a lot about that process.

Elisha Yaghmai

The practice of medicine is a lot about doing that mental process at work. But the only way you can do that is and I think the only way to sort of train yourself right, is you have to run through thousands and thousands and thousands of patients, right. To pick up on all these patterns, all the variations, all the things that go on.

Elisha Yaghmai

So in other words, and, you know, going back to our discussion from a couple episodes ago, you know, I'd said the thing for me that was the unforgivable sin in medicine was really was laziness. It wasn't lack of knowledge, it was laziness. And the reason for that is this, right? The only way to learn stuff is to beat your head on it over and over and over again.

Elisha Yaghmai

So you have to see patient after patient after patient, right? To just keep training yourself, right? Because it's not like, you finish residency, right? And you've now seen everything there is to see and you know, all the cases right? That's that's totally not true. Right? There's so many more there's so many variations. And then you see that rare thing that you've only ever read about in a textbook, right?

Elisha Yaghmai

You've never seen it before in your life. Yeah. Now you see it because it's the it's the 40,000 patients that you've seen. Right? Right. That's the one where you finally got that one in a million type case. Yeah. To finally walked in your door and you got to see it for the first time.

Jo O’Hanlon

Right?

Elisha Yaghmai

So if you don't want to do that right, if you don't want to do that process of running through those folks, it will be much you will gain skill, generally speaking, at a slower rate.

Jo O’Hanlon

Right.

Elisha Yaghmai

You know.

Jo O’Hanlon

So as someone who did that a lot and was really proactive in doing that, it sounds like of getting the bang for your buck in your, you know, your education life. Did you feel prepared when you went to Parsons? Was that? A Yeah, that was the feeling.

Elisha Yaghmai

It was, yeah. I mean, there still there still some things to learn.

Jo O’Hanlon

You know, it's like to me I'm like, man, it seems intimidating to be the one that's in charge of the hospital. Basically, for a town where it's like, what if it is one of those crazy cases that comes in that you've never seen before and not for anybody, but then it's you and your new and you don't know if this is, you know, you just didn't have as much under your belt.

Jo O’Hanlon

Was there cases like that that were really stressful in that way of like not having the support above you that you'd had prior?

Elisha Yaghmai

No, I mean, what I would say there were two things. So one was that obviously I still had all the contacts with all the physicians that had taught me and trained me right. So I still had those people. So periodically I would call them up and say, you know, hey, here's a case I'm seeing, right? And it's not going the way I would expect.

Elisha Yaghmai

You know what you what can you tell me right then very frequently with the they didn't see the patient again, right? Yeah. These are people that were often ten, 15 years ahead of me. Right. Right. That many more thousands of patients.

Jo O’Hanlon

Right. And those lines were you know, those calls were answered.

Elisha Yaghmai

Exactly right. So the line of communication was open. Right. So then this is kind of what I mean, right beside the point was that they could hear the same case that had me a little bit mystified. Right. And be like, yeah, you know, it's this, right? Yeah, this is what's going on. Do this, do that. Right. Yeah.

Elisha Yaghmai

Solves the problem.

Jo O’Hanlon

That flowchart that's ingrained in them has that pathway a little clearer. And I've seen it before.

Elisha Yaghmai

It's because they've, they've seen so many thousand more patients. Right. Yeah. So that stuff for them is they're.

Jo O’Hanlon

Nice, you know.

Elisha Yaghmai

So that made it, that was one thing that was helpful. Part of it also was just the payoff to all the intensive training and work that had been done before. Yeah, right. In terms of being able to handle things or do the procedures or whatever or diagnose things right, that was there. And then, of course, you know, there still were situations that were, you know, stressful and learning and it was like the first time I'd ever seen it and there was no backup of any kind.

Elisha Yaghmai

Right. And you have to navigate that.

Jo O’Hanlon

Right.

Elisha Yaghmai

And some of it, I think, also is just the typical sort of younger. You're too dumb to know that you shouldn't be doing this. No, I wouldn't say I wouldn't say it is true that you shouldn't be doing it, but it was just an option. I didn't go in thinking about what all the things that could go wrong.

Elisha Yaghmai

Right, Right. I went in thinking about this is an opportunity to essentially test the skill that I hope I acquired right. Against a challenging situation, which is being a solo person, right in a in a difficult environment.

Jo O’Hanlon

Personality wise, do you do well in stressful situations like that of like rising to a challenge?

Elisha Yaghmai

I would say yeah, I would say so. I like those, especially if I feel it's if it's meaningful, that.

Jo O’Hanlon

Be the.

Elisha Yaghmai

You know, I would say I wouldn't. I'm not. I think, you know, I certainly had experience as a sort of wilting right under stress. I think I have had that experience. But I would say that the more worthwhile that I felt that it was, yeah, if it came down to it, probably the best way to describe it, if it came down to kind of a stamina type situation.

Elisha Yaghmai

So needing to withstand the stress over a prolonged period of time that I felt went reasonably well. Okay. And so and this was that kind of event.

Jo O’Hanlon

You've been.

Elisha Yaghmai

Practicing for months, for.

Jo O’Hanlon

Years now, For.

Elisha Yaghmai

All year.

Jo O’Hanlon

Exactly, Yeah. What were some of the stressful or like just infrastructure breakdowns of being in the rural setting. I mean that has its own.

Elisha Yaghmai

It does, yeah. So we would have trouble I'm sure we would have situations where so to give you an example, like if I ordered a radiology study in the urban environment. Right, I'd get the read back within an hour or two.

Jo O’Hanlon

Okay.

Elisha Yaghmai

I wouldn't get the read back to three days.

Jo O’Hanlon

really?

Elisha Yaghmai

Yeah. So I'd be sitting there saying.

Jo O’Hanlon

Because it has to like.

Elisha Yaghmai

So a radiologist has to read the study.

Jo O’Hanlon

So you have to you didn't have a radiologist in-house.

Elisha Yaghmai

It was there while you were at the readings were just very, very slow. Right. And took a long time. Right. So so here again. Right. You said there's all these differences in how they're delivered. So it's a different animal when I can order an X-ray or a CAT scan and expect to get the read back nearly immediately.

Jo O’Hanlon

Right. Right. Then you might even have the patient still there waiting. Right.

Elisha Yaghmai

So, absolutely right. So what if I ordered CAT scans because I'm trying to rule out a certain condition, right? Well, if it takes three days for the read to come in, that means I need to keep them on the therapy that I'm trying to remove. Right. Because I need to.

Jo O’Hanlon

To verify that.

Elisha Yaghmai

I need to verify. They don't have this before I can take this therapy away. Right. Well, I can't do that until I can actually get the report right. Yeah. So if there's lengthy delays in getting the reports of my diagnostics and lengthy delays instantly, this is a very common problem in rural health care and certainly in Kansas, but probably across the country.

Elisha Yaghmai

Yeah, very common problem, right? You order the diagnostic and it takes a lot longer to get than it takes in an urban environment or a large kind of tertiary hospital. Right. And people don't appreciate the difference that that makes. Right. Yeah. Because again, it results in, you know, prolonged exposure to a medication that maybe you don't need delayed diagnosis, not making a diagnosis.

Elisha Yaghmai

People just don't order the study because they're like, this is going to take it's going to take five days to come back. Forget it. Right. I'm just going to make a guess. I'm going to make my best guess and we're just going to go on my best guess, right? Because I can't get this information that if I was a hundred miles over.

Elisha Yaghmai

Right, I could get very quickly. That would absolutely change my therapy right.

Jo O’Hanlon

Which in this case, it was like if they had had another radiologist on staff, would that have been potentially.

Elisha Yaghmai

Yeah.

Jo O’Hanlon

I mean, not, not yeah.

Elisha Yaghmai

I can't speak.

Jo O’Hanlon

To that speak to this hospital specifically, but like, you know, it sounds like there's lack of time and just there's constraints on maybe even the tools that are available as well in some situations. But that one sounds like maybe just more personnel like, yeah, in the back.

Elisha Yaghmai

To some kind of help, right? Yeah. If I recall correctly, the doctors trying to do stuff was, was trying to do interventions and other things right at the same. Yeah. So in other words it's not like so the only thing I was doing is sitting there and trying to read films where he's also trying to do half a dozen other things at the same time.

Elisha Yaghmai

Again, shortage environment, right? So we've got one person wearing multiple hats at the same time trying to satisfy all these constituencies. And it's challenging, right? Yeah. And, and again, my my point here, this is and I want to be careful here. The point here is not that that person's terrible. Right? That's the point.

Jo O’Hanlon

Here.

Elisha Yaghmai

Again, you have a system issue, right? Right. You have a system issue, which is what we have is an isolated provider who's trying to do multiple things simultaneously. Yeah, it's impossible to do all of them simultaneously. Right. It's not.

Jo O’Hanlon

Possible. Right.

Elisha Yaghmai

Have we systematically, as a system, I should say, stepped back to say, number one, do we have a problem? Right. Well, the answer is yes. Our problem is our diagnostics are delay, right? Yeah. Number two, why do we have this problem? Number three, what solution are we going to propose the solution of, hey, you know, tie up your your sneakers, right.

Elisha Yaghmai

And run a little bit faster is not is not the solution. Right. Right. Yeah. But that aspect of it. Right. If it was going on at least, you know, I wasn't aware that that process going on, all I had on the front line was when I order stuff, it may or may not get read and it may take X number of more days than I'm used to.

Elisha Yaghmai

Right. May be going out. So that was that was an issue. Another issue that was happening in that place was they would have the emergency room do that. So for nighttime admits that would come in. Sometimes they would call me and sometimes they would have the emergency room doctor. Right. The orders. Right. Okay. Now you say, well, that's not such a bad thing.

Elisha Yaghmai

Right.

Jo O’Hanlon

And what is part in the layman's question? So what is right in the word?

Elisha Yaghmai

Yeah. So when when a person gets admitted to the hospital. Right. There's a series of admission orders. Right. And it could be however long. But it's basically the the the hospital person providing care in the hospital. Right. Assesses the patient. Yeah. And decides what what do I think this is and what do we need to do about it.

Elisha Yaghmai

Right. Okay. So the problem is that there is emergency room people who mostly handle outpatient stuff, right? You're walking in with your sore throat or your broken leg or stitches and they fix that stuff for you. Right. And they send you home For most emergency room. People don't do a lot of inpatient time, meaning they don't they don't follow even if they admit you to the hospital.

Elisha Yaghmai

Right. They don't follow you over the x number of days that you need to be in the hospital. You're not doing that aspect of it. Their job is acute right now. What's happening in this moment for the next couple of hours until I and move you somewhere else or I fix you and you go home. Right? Right. Well, you know, in in the in the mind of a lot of hospitals, a doctor is a doctor is a doctor.

Elisha Yaghmai

Meaning we have a doctor here in the doctor can do everything. Well, that's not actually true, right? It's not actually true. And I would say it's you can appreciate a little bit more if I said, well, I've never done brain surgery before, but I'm a doctor. Right?

Jo O’Hanlon

Right.

Elisha Yaghmai

Yeah, right. Yeah. So, you know, clearly I should be able to operate on your brain successfully. Right. And you might have a problem with that. Right? If I representative that way. Right. But this is what we do. So we say, Hey, will you normally work in the emergency room? The emergency room isn't. It's almost the hospital in some ways, right?

Elisha Yaghmai

So we can just have the E.R., just do what the hospital does. Right. This is this is not uncommon, right? This is an approach they will take. And it's not again, it's not that the E.R. doctor couldn't get it right. It's not that they can't because it's that averaged over a bunch of people. Right. You're going to have some folks that are pretty good at it and some folks that aren't very good at it because it's really not what they do right now.

Elisha Yaghmai

They've done it for years. It's been a long time since they were anywhere near residency programs to do this. Right. They didn't have any of this. But you're asking them to put on a very different hat. And why are you asking to do this again? Shortage situation. Right, Right. So you're saying, hey, we've got this one doctor here.

Elisha Yaghmai

This is all we can afford to have out here, right? Yeah, We don't have any other night coverage. So we're going to have the E.R. doctor put in the orders. Right. So one of the E.R. doctors, you know, for example, there was a there there's a older lady that came in with a low sodium. Right. So he put her on an IV fluid at a very high rate.

Elisha Yaghmai

That made her sodium drop even more. Right. So when I walk in in the morning, she's having a seizure. Right? Right. And I'm like, she survived. Okay, So she survived. Okay. So that's but when I went and looked at this, I was like, this was completely predictable and prevent. Right. Right. This never needed to happen. This lady didn't need to have a seizure.

Jo O’Hanlon

Yeah.

Elisha Yaghmai

What happened was the person right in the orders, Whatever happened. Right, Right. This was the wrong person to be doing this. Yeah. And it caused a harm.

Jo O’Hanlon

Wrong call, right.

Elisha Yaghmai

Was the wrong call, and it caused a harm. Yeah, and. But why is this happening, right? Yeah, well, it's happening because we don't have enough staff here, right? So we're just making do right with whoever and whatever and you can put together.

Jo O’Hanlon

This might be a bigger question for later on. But what you just said, like, we don't have enough here. Yeah. Is that a money issue.

Elisha Yaghmai

Yes.

Jo O’Hanlon

Is that.

Elisha Yaghmai

It? It's a well one is why One is geographic isolation. Right. You're in a town where it's, you know, not that many people going to want to come. Yeah. It's a small town. It's in a rural area. It's not A lot.

Jo O’Hanlon

Of medical help is possibly small.

Elisha Yaghmai

The list of people that want to come in is relatively on a permanent basis, right? Relatively short. They're people that will come out on a so-called locum tenens basis. Right. But you're going to pay a ton of money per hour and that's prohibitive. You can't do that forever because it's very expensive. Yeah. So you can get who you get.

Elisha Yaghmai

But when you're talking about sort of a stable long term situation, the list of candidates is usually usually short. Yeah. So you can't get them that way, right? And then on top of that, you know, even the ones that you get right, in some cases, you know, you don't have you don't have the pick of you know, there's there's 300 applicants for this job, Right.

Elisha Yaghmai

You have to write one. Right. Right.

Jo O’Hanlon

So you're like either yes or no, either yes or no.

Elisha Yaghmai

Right. And it kind of doesn't matter. Name somebody if you got to have a person there, you've got a person there. Right. And so whether they have all the experience you would want or whether it's optimal, you know what I mean? You can't be that picky in an environment of shortage. And so this is again, this is really a system problem.

Elisha Yaghmai

Right. And so the issue later on. Right. One of the motivations to start the virtual care right in rural was a realization that, okay, what did we need to not have that lady have a seizure? Right. What we needed was somebody that was available that knew the right thing to do, right.

Jo O’Hanlon

That's not our doc, but someone who was more not.

Elisha Yaghmai

That hard on whatever was specialty aside. Like we needed someone in the proper position who was available at that time to make a better decision for that. Right. Right. That is what we needed. And we didn't have it and we didn't have it because in that context at that time, the only way to get a doctor there was to physically transition transport.

Jo O’Hanlon

Right.

Elisha Yaghmai

Of opposition to the place. But in reality, that's not true, right? Those the correct decision could have been made with just the data if you just had the lady still in her labs and whatever else you could have known. And that's probably a poor choice. Right? Right. Either not do that.

Jo O’Hanlon

Without ever actually.

Elisha Yaghmai

Even being there. Right. But this is just like mind blowing concept to many people in health care and certainly to many hospitals. Right? Yeah. That you what you need is the right mind in the right place. Not necessarily the body.

Jo O’Hanlon

Right?

Elisha Yaghmai

Right. Yes, not necessarily, but but many hospitals have opted for I want the body. Right. Right. If I have the person here in front of me, that's clearly the right thing to do. But it's not because if they don't have the right knowledge, their body being there, it doesn't actually help your patient anymore. But it makes you feel better because you have filled a starting slot, right?

Elisha Yaghmai

So there again, we had we had a system problem, right, that was going on where the care was worse than it should be because I use it myself as an example, Right? So I'm here as a brand new graduate, right?

Jo O’Hanlon

Yeah.

Elisha Yaghmai

And the problem that that happens a lot of times is when you go out into smaller environment, right? You in some cases, you may be the most knowledgeable person in your in your little tiny environment. Right.

Jo O’Hanlon

Right.

Elisha Yaghmai

That doesn't mean you know everything, right? Definitely means you're the most knowledgeable person in this environment. Right. You may be a you may be a small fish in an even smaller pond.

Jo O’Hanlon

Right. Right.

Elisha Yaghmai

You know, and this is the problem. Right. And so it just give you a example, like when I think now I think back to some of the some of the decisions that I made then. Right. And I'm like, you know what? Yeah. You know, I probably I should, you know, now. Now, knowing what I know now, I would have done something different in that situation, right?

Elisha Yaghmai

I wasn't necessarily that somebody was hurt by it a lot of the cases, but it's like I could have probably gotten to the end of that case faster.

Jo O’Hanlon

Right.

Elisha Yaghmai

Right.

Jo O’Hanlon

Well, like you've mentioned on like like, you know, how's the show? How ridiculous it is. When we were chatting earlier last week, I think you mentioned like you would need to have 20 fellowships, like, you know, all these different things. You know, the amount of knowledge that he knows. It's like that's a great example for laypeople. I feel like we're it's like we're given this spot of like, our doctor knows all of this, right?

Jo O’Hanlon

And then we see something very different in the room. Yes. Often because it's a very short amount of time that we're with the doctor anyways, so we really don't even know what they know. Yes. So there's this dichotomy of like expect eating house. Yeah. And then getting any doctor who's treating you in a different way or something. And then that being a frustrating thing where you're like, well, you're supposed to know this much and it's like really, it's somewhere in the middle is true for someone coming out of residency and becoming an attending physician.

Jo O’Hanlon

It's like you. We shouldn't expect a doctor in that realm to have that much knowledge, right? But I think what you said before of the laziness piece, like that's the big piece that I see. I'm from a small town also. And so that I've had really good instances with some of our doctors who followed us through all of our I mean, until I moved out of that town, my parents still see these people.

Jo O’Hanlon

But it's like because they were the ones that similar to you have dug in and been really curious about things more than either feeling like they know everything themselves and like, you know, it's like when they I feel like as a as a patient, I've been so interested in a doctor whenever they've shown interest in me, where they're like, I don't I don't know, let me I'm going to do some research on this.

Jo O’Hanlon

I'm like, okay, I respect that answer. Like, because if you knew everything at the start, I mean, why, why couldn't you just why couldn't I just call you? Yeah. And I mean, that answer that sometimes is you can, though, right? And so that's where. Can you talk a little bit about the the rural just briefly, because we haven't really talked before about free state very much.

Jo O’Hanlon

And so can you give a brief synopsis for our listeners of what the rural side of the free State piece is?

Elisha Yaghmai

Yeah, I mean, originally so originally the formulation of free state was to try to address some of these issues, right? So it was to say, let's use virtual technology to provide more reliable and potentially greater expertise.

Jo O’Hanlon

Yeah.

Elisha Yaghmai

In terms of more reliable coverage and potentially greater expertise to small towns that otherwise would not have easy access to it. Yeah, that was the basic concept.

Jo O’Hanlon

And this was before other telemedicine operations.

Elisha Yaghmai

Yeah, this was just started in 2014. Yeah. So it was before it was a hot topic or anything like that. And the, the point was also to reduce the cost of care. So to give you an example, a lot of rural facilities, you know, they might be paying two or 300 more, more dollars an hour right. To have somebody come out.

Elisha Yaghmai

But they did.

Jo O’Hanlon

In-person.

Elisha Yaghmai

In-person to have them come out in-person, but they didn't have the patient volume. Right. And then on top of that, they had the restriction of they can only get who is someone that wants to come there who's also actually available at that time. Right. And is able to do the travel Right. Yeah. So that the list of candidates actually fairly small.

Elisha Yaghmai

Right. And then you didn't necessarily have control over the quality at all. Went on of what went on and there were people that was who was coming in, who's actually coming to you. Right. This was this was you know, this was the problem. Yeah. So you're paying a ton of money in a way that at a price that's unsustainable for you long term as a facility.

Elisha Yaghmai

You don't have a patient volume for it. You have no control over the true quality or expertise of the person that's coming in. Yeah, especially if they're coming in on kind of a random one off basis, right? They come and do a week, a year or something. I mean you can't see them on enough.

Jo O’Hanlon

Is that pretty common rural areas we have like the.

Elisha Yaghmai

Top.

Jo O’Hanlon

Visiting docs.

Elisha Yaghmai

Very, very common.

Jo O’Hanlon

Yeah. Super short term like that.

Elisha Yaghmai

You know, here again to kind of take it back to my experience then. So one thing to happen, I'll never forget this. I had a guy come in to do to do a coverage for me on a weekend right. Yeah. Over that weekend he killed two of my patients straight up. Yeah. You just became in mismanage them. I came back and they were dead.

Elisha Yaghmai

Right. Well, one of the guys said that I. One of the guys. I mean, I came in to get silence. Sign out from him. Yeah. On Sunday night. And he said, yeah, you know, this gentleman's been here. You know, he's real sleepy. Real sleepy. Obviously, I'm having to wake him up, you know? And I'm like, okay. I was like, How long has he been asleep?

Elisha Yaghmai

since, you know, Friday. You know, usually, as I said, I'm sorry, What was. The guy's been asleep since Friday. Like, what have you. What have you done? no. You know, he's just real sleepy. You know, we just said I think it was a urinary tract infection. I think that's what's going on.

Jo O’Hanlon

You know, But he was an admitted patients.

Elisha Yaghmai

So meditation. Yeah. And I'm like, you think he has a urinary tract infection, but he's been unresponsive since Friday. It's now Sunday night and you haven't done anything with him. Anything at all? Nothing. Right. The guy died, right? The guy died. He had he had a massive stroke, completely all completely missed. And nothing was. But he didn't have a urinary tract infection instantly.

Elisha Yaghmai

And the data was very clear, actually, when you looked at the labs, very clear. He never had that in the first place. Right. This was a locums who they brought in. Right. To provide me with respite for a weekend. Right. So this month. Right. So I'm here is the main guy working all around the clock and getting calls.

Elisha Yaghmai

Right. So every now and then they try to give you a break. We're bringing somebody in, right? So they brought in this this person and this is what he did. And I forget what the other case was, but it was very similar where it was just, wow. So the decision making was just just indefensible. It was just absolutely indefensible.

Elisha Yaghmai

Right.

Jo O’Hanlon

And these are regularly practicing doctors from elsewhere that are leaving.

Elisha Yaghmai

That person is actually that person was a fellow in a in a training in a special subspecialty training program right from the Midwest region. Yeah. Yeah. He was a fellow at that time. This was this is what went on. Right. And so I was like, wow, okay, this is like, this is just terrible.

Jo O’Hanlon

Yeah. I mean, I think progressions for this, like, for that doctor of like does that well.

Elisha Yaghmai

What the repercussion was, you know, I talked to the hospital and said we can't ever have this guy back or never come back.

Jo O’Hanlon

Him them though to other.

Elisha Yaghmai

No it doesn't No.

Jo O’Hanlon

Man.

Elisha Yaghmai

It doesn't goes to the company that brought him in. If they choose to ignore it or not to do anything with it, they choose to book him for future assignments. Yeah. I mean, I have no idea what they chose to do. Yeah, but if they choose to do that and there is a strong financial incentive to choose to do that, that's a whole discussion of the locum tenens industry, which is different.

Elisha Yaghmai

Strong financial incentive to choose to do that. There will be, unless you file a formal complaint like you put something on their license or whatever the case is. This stuff, this stuff just goes nowhere.

Jo O’Hanlon

Which would that have to be? Like families person.

Elisha Yaghmai

So there could be families, there's a civil lawsuit, or it could be that the facility or somebody could file a report with the state, right. To try to say, Hey, here's know we have a complaint against us. That's a that's a lengthy and often complex process. Right. And so a lot of times stuff like this just kind of goes on.

Elisha Yaghmai

It just kind of goes on. And that's if it's even detected. Right. Which is a whole nother issue. Sometimes it's not detected right in the first place. Nobody even realizes what went on.

Jo O’Hanlon

Because it's just like, yeah, this patient had a urinary tract infection and then went to sleep and died.

Elisha Yaghmai

Yeah, Yeah.

Jo O’Hanlon

No, no, it's not the story.

Elisha Yaghmai

The story. That's the story that goes on, right? You know, is this terrible? And who knows what happened. Right? But, you know, this is just, you know, probably their time to go. And so, you know, it was just their time that was the that was the end. Right. So there again, it's an example of you have a system problem, right?

Elisha Yaghmai

You have a shortage of people you brought in who you brought in. They're not doing a great job. You have a back in, you have a forward facing system problem, which you described, which is this person doesn't seem to do a good job of managing in this situation. Is there any monitoring of that? Does anybody know about it or any feedback given?

Elisha Yaghmai

Is there any additional education? Is anybody investigated? In other words, I'm.

Jo O’Hanlon

Not thinking about like Catholic Church. You know, the priests that have done egregious acts have been continue to be shuffled to other places. And I'm like, you're talking about traveling doctors who are hired for a week at a time, very easy to not have oversight.

Elisha Yaghmai

There is an element of that in medicine with with absolute certainty. Yes, there is. There's an element of people know. People know. Yeah.

Jo O’Hanlon

But it's too hard to jump through all the.

Elisha Yaghmai

Possible.

Jo O’Hanlon

Things.

Elisha Yaghmai

So there's several other things. One is it's hard to jump through the hoops to. It becomes very political very quickly, right?

Jo O’Hanlon

Yeah.

Elisha Yaghmai

You start burning the house down right then, you know, that can get really ugly really fast. Right now you're getting dragged into stuff and it's very you know, and the fraternity of physicians is relatively small, right? Committees. Everybody kind of knows everybody or, you know, there's some shifts. You see what I'm saying, right? Yeah, It's very similar. So it's like, well, you know, yeah, you know, that was done wrong, but, you know, there's probably some extenuating circumstances.

Elisha Yaghmai

you know, it's not that bad. A lot of that goes on. And part of the reason a lot of that goes on is, is some of it is the politics and stuff I've described. Some of it is also the longer you practice, you develop some mercy because you also make mistakes. Right? Of course, you try not to hope, not make mistakes, that ridiculous and religious right.

Elisha Yaghmai

But you make mistakes right? Right. And as you do that, you start to say, well, okay, you know.

Jo O’Hanlon

I there's mistakes, but then there's gross negligence.

Elisha Yaghmai

Yes, there's a difference. Right. And I describe that really as gross negligence. Right. But what I just described doesn't exist. Right. But but you make mistakes. And as you do that, I think it's true for human life in general. Right. You you go through your life and you mess things up and you become more merciful, right as time goes on, Right as you get older.

Elisha Yaghmai

And that's true. The problem is you don't have a way to know, is this a pattern of behavior, Right. Or is this just somebody had a really bad day? Right. Right. No, because I don't know this person. Right.

Jo O’Hanlon

Well, you're not even there like the same time that they're that.

Elisha Yaghmai

This is the issue. Right. So I don't know what went on that I didn't even know about. Right. Patient came in and left before I got here. I don't know what about it, Right. I don't know about any of their past practice habits. Right. Right. So I don't have any baseline to know them. And so it makes it very hard to say, what is this again, a one off situation or is this somebody that really shouldn't be doing this?

Elisha Yaghmai

Right. Right.

Jo O’Hanlon

This is happening in multiple places, but they're traveling this year.

Elisha Yaghmai

And the answer is nobody, to my knowledge, knows that information. It is knowable information, but nobody knows that information in in actual reality, this is this is one of the problems. Right. That goes on. And and even I will say, even when we do know it, even then that's when you get into the politics and the stuff that goes on.

Jo O’Hanlon

Being able to do something about.

Elisha Yaghmai

Get around, you know, nothing really exactly happens. And they just sort of keep going. Yeah. That that also goes on and it tends to go on most often in smaller environments, again with a C or eyes, right, Right. Watching things and few people that know. But it goes on all over. It's not like the all the small businesses are the only ones that have that problem.

Jo O’Hanlon

That's interesting. We're about out of time, but I want to ask cause I know that from there you went to Seattle, right?

Elisha Yaghmai

I did. But I should add, before we jump to. Yeah, if we have the time. One other system story.

Jo O’Hanlon

Okay.

Elisha Yaghmai

Yeah, that happened in this so there was also patient is a young man who came in for a tonsillectomy went very badly. He starts bleeding out and he died Right he died from this but but as part of this process before he died, they were trying to get an early on him and everything was just filled with blood.

Elisha Yaghmai

And it took a very, very long time. So he took it. He took anoxic injury to his brain. Right. So this is by any means this is a tragedy, right? I mean, this is what.

Jo O’Hanlon

Does oxygen and I'm.

Elisha Yaghmai

Sorry. So he didn't get enough oxygen supply to his brain for too long, right? Yeah. So in this situation, at that point in time, right at that point in time, there was some question about could you do basically, could you cool the body down right to try to stave off some of the worse the injury and the evidence on it wasn't great even then.

Elisha Yaghmai

We kind of knew it wasn't great. But yeah, so here I am. I'm in this this small hospital isolated from everybody. And I'm like, I've got a 30 year old here who is dead now, right? Due to a surgery gone wrong.

Jo O’Hanlon

Yeah.

Elisha Yaghmai

I need to send him somewhere bigger than here, Right? Because I was like, if he's going have any any chance of survival, he's got to be somewhere other than here with me in a place with limited resources.

Jo O’Hanlon

Right?

Elisha Yaghmai

And I called all over the place and I got turned down over.

Jo O’Hanlon

For, like, medevac kind of stuff.

Elisha Yaghmai

Yeah. You know, I tried to call other hospitals and say, like, we please take this guy.

Jo O’Hanlon

Yeah.

Elisha Yaghmai

The the runaround. I spent hours and hours and hours getting run around on. Well, you know, we don't know. I mean, you know, the evidence on, you know, hypothermia in this situation is really not good. So I don't know that we'd really have anything to offer him. Right. And I'm like, he's 30 and he's going to die. Right.

Elisha Yaghmai

And I don't have anything here to address this with. Yeah. Yeah. But, you know, I don't know that we could help him in our massive, you know, Quaternary referral center. We could help. Well, you know, we might take him, but, you know, I need to have my subspecialty service really on this also. And they need to agree to take him first before I would take him.

Elisha Yaghmai

You know, because if they're not going to agree to do this, so you need to call them and then get them to approve. And then if they approve, then you can call me back and then we can have another discussion about this. Right. And meanwhile. Right. This guy has taken a brain injury and the clock I'm just watching the clock ticking.

Elisha Yaghmai

Right. And I'm trying to call around and I can't I can't reach people. They don't call me back. When they call me back, they give me runaround. They give me a denial that's just based on they really just don't want him coming there to die. That's the real answer. Yeah. Yeah. And there's no thought in any process of this that this is a person who has just had a tragic event happen to them as a result of exposure to the health care system.

Elisha Yaghmai

Right. Right.

Jo O’Hanlon

A routine.

Elisha Yaghmai

A routine procedure that usually goes well. It didn't go well in this case, right?

Jo O’Hanlon

Yeah.

Elisha Yaghmai

But there's no there's no coordination there was no way for me to know who had beds available. Everything was done in a manual prostrate. Had to sit there and say, okay, I have to call this place. Then going to call that place that this one, then this one, then this one and this one. This one right. And then I get a wide variety of responses.

Elisha Yaghmai

Yeah, right. And so I spent three plus hours, right. Just begging to try to get this this patient transferred to somewhere that could do anything for him more than what I could do right here again.

Jo O’Hanlon

And there's like here you say that in my mind. I'm like, I'm shocked that there's not a place that is like your go to place of like.

Elisha Yaghmai

There's not.

Jo O’Hanlon

This is a bigger hospital in this whole they're big brother and well, we always send patients here.

Elisha Yaghmai

You can try. Yeah, but they, they, they may not have bedrooms.

Jo O’Hanlon

It's not like our regular they.

Elisha Yaghmai

They just may not accept. Yeah. This is very common. Right. So they just they'll come up with a reason not to accept this. Extremely common to see. Right. They'll be a reason not to accept. And so you on the in small hospital around the rural site are stuck with a patient that you know you can't help.

Jo O’Hanlon

Wow.

Elisha Yaghmai

But no one will take them for any number of reasons on their side.

Jo O’Hanlon

But I'm assuming that the main one is not lack of beds or at.

Elisha Yaghmai

That time it was. Now it is these days is right. No, back then it was not lack of beds and plenty of beds that used to have that. Plenty of beds. Right. It'd be various other reasons that they would come up with to not take the patient.

Jo O’Hanlon

Is there some sort of financial like type penalty or advantage to not having people die in your hospital?

Elisha Yaghmai

Yeah. If you're if your death rate if your death rate is too high. Right. That's bad.

Jo O’Hanlon

So they're like hesitant maybe on some of these.

Elisha Yaghmai

Yeah. If you're going to take it, you take one that's probably going to die. Right. That that may or may not affect your statistics.

Jo O’Hanlon

Isn't that against a doctor's oath.

Elisha Yaghmai

Yes, it is. Yes, it is. But yet it's a statistic to which payment is tied. Right. So. Right. So this is a consideration that goes on What insurance? The patient has a huge consideration, Right. You get that question.

Jo O’Hanlon

Out of time. yeah.

Elisha Yaghmai

Yeah, yeah, yeah. No, they're places they will not. They don't want to talk to you unless the patient has the right it. So they'll do a financial analysis before they will accept the transfer. It's not a question of what can we do for them medically. Wow. It's. How would this be paid for by anybody? Right. And if it can't be paid for, then don't call us.

Elisha Yaghmai

Right? We don't care if we have a better or not. Like we're not going to be able to accept that patient. And the answer is because they don't have the right insurance.

Jo O’Hanlon

Right. And like, if the patient wants to walk into their E.R., they'd have to.

Elisha Yaghmai

They'd have to be obligated.

Jo O’Hanlon

By law from another hospital like they have to receive.

Elisha Yaghmai

Them. That is correct. They have to receive them. And so reasons reasons can be as as bad as that. Yeah. Sometimes it's also just, you know, the doc on the other side just having a bad day. They're just overloaded and busy. Right? I mean, this is a real thing. These are human because they're tired. Like, you know what?

Elisha Yaghmai

I don't want to deal with this. This is going to be a train wreck of a case is going to be very difficult. I've already I'm on my 10th admission for the day. Right. I have too much already going on here. This just I just don't want to deal with it. Right. So I'm going to come up with an excuse to punt this case.

Elisha Yaghmai

Right. And you say again, from the perspective of an outsider, you say, well, that's ridiculous, right? This shouldn't be the case. You know why? Why would you? You're jeopardizing the life of my family member, right? Because you're tired, right? You know. Right. And that's not wrong. Right. That's that's not a wrong emotion. The problem is the opposite side of it is also true, right?

Elisha Yaghmai

They're on there. They're on their 10th straight admission. They're getting beaten into the ground right. They don't have adequate support on their side. They're dealing with electronic medical record that makes their life even more miserable. Right.

Jo O’Hanlon

So but really frustrating to have that whole situation. Right. I mean, on either end, like.

Elisha Yaghmai

This is the problem, right? So, again, these are all these aren't individual problems, right? It's not like, that's a that was a bad doctor. You did decide. Right, or bad doctor on this side. Yeah. These are system issues where there's a there's a total lack to give you an example, there's a lack of collaboration. So for example, we should know which beds are available, where Red Cross at least across the state.

Elisha Yaghmai

Yeah, at least across the state, Yeah. Every hospital has an open bed. Should be in a database somewhere that we could just go to and be like st so-and-so's. They got a bed, they got an ICU bed that's open right now. Right. I can apply for that to give my patient that type of that type of information should be shared.

Elisha Yaghmai

It is not shared. Right. What resources this place has versus that place that should be open information. It is not shared. Right. Really. So you call them and you don't know necessarily you assume they have X specialty or Y diagnostic machine. You don't actually know that. Yeah. So instead you have to go through the process of calling them to find someone.

Elisha Yaghmai

Or more often these.

Jo O’Hanlon

Days like you it's you call it right. Does amazing to me like to hear that where I'm just like wow. So my doctor was right when I'm waiting for that crucial move.

Elisha Yaghmai

That's correct.

Jo O’Hanlon

He's in the other room doing this.

Elisha Yaghmai

Yeah. In a small environment, that's up to the right. Even a bigger, you know, somebody, some member, they're on his team, right? He's making the call.

Jo O’Hanlon

Yeah.

Elisha Yaghmai

To try to do this or calling around to try and then you start to do your you have to do your doctor doc check out. All right. Describe those things. I mean, all of this is happening and you're you look at it and say, this is all chaos. Right? And it's chaos because, yeah, these hospitals all have different ownership, right?

Elisha Yaghmai

They have different electronic medical records. They have different staff that often have no connection to each other whatsoever. Right. And there is no attempt to collaborate anywhere, unless they're all in the same system with the same ownership. There is no attempt to collaborate between any of them and COVID, which we saw many years later. Just highlight just put a huge spotlight on what a disaster it is when you have 15 different actors, none of whom know what the other is doing right?

Elisha Yaghmai

In many cases right, and are not collaborating in any obvious ways to decide how to use the resources that we have efficiently.

Jo O’Hanlon

Right? Well, I mean, in one way, not that it was positive in many ways, but in the public's knowledge, at least like during COVID, It was an interesting part because we were getting regular news updates of our hospitals of how many beds, you know, what percentage were full and what were empty. And I was thinking that when I was reading these days where I'm like, I don't know how this compares to normal because we've never been given this information before.

Jo O’Hanlon

Yeah. You know, And so I think that that's like you said, it's shining a spotlight, I think, for the public as well. In a way, it was like it started to make me question those things. Like what? Yeah, I don't this is I can see the stats now, but I don't know what this is compared to except last week COVID stats and then the week before COVID stats.

Jo O’Hanlon

But like prior to COVID, like what were the stats? Because I have no idea and I didn't need to know necessarily before, but it is an interesting piece where it's like, you know, we have such transparency of information in a lot of realms of our lives, right? And you would think that at least between institutions, there would be some sort of piece to that.

Jo O’Hanlon

But no, not at all.

Elisha Yaghmai

Usually there is not usually there's not. Yeah.

Jo O’Hanlon

All right. Well, that is our time. Next time, we'll be talking about your trip to Seattle and what that was like. I honestly you've told me that you were at a referral center. Is that right? Yeah. Yeah. I don't know what that is. So we're about to find out. Thanks, Leisa. Thank you, guys.