Mark Briesacher, MD: Hi, I'm Mark Briesacher, I'm the president of the Intermountain Medical Group, and I'm here today with Dr. Karyn Springer and Dr. Mark Milligan, two of our family medicine leaders in the medical group. I think all of us kind of met in the same way and that is through our service on the medical group board.

Mark, I think early 2000's, maybe 2002/2003— I had joined a couple years before then and you joined the board.

Mark Milligan, MD: Yes, around 2001/2002.

Mark Briesacher, MD: And Karyn, a little bit later, 2009.

Karyn Springer, MD: Yeah, about eight years ago.

Mark Briesacher, MD: Things are a little bit different today then back then. It's been an interesting evolution over time. We certainly have had a fun time getting to know each other, meeting wives and husbands at our different functions. I have to share with you Mark, I have this idea of me doing some cameos with your band that I have sometimes have thought about in my mind as I am singing at my loudest in the car, never publicly.

Karyn Springer, MD: Singing in the shower?

Mark Briesacher, MD: Not right now!

Mark Milligan, MD: That's the safest place!

Mark Briesacher, MD: Karyn knows this, Mark has an amazing band that actually we have hired multiple times at some of our medical group board meetings. Boy, do they do a great job and a lot of fun.

Karyn Springer, MD: They are a lot of fun.

Mark Briesacher, MD: And people dance when his band is around.

Mark Milligan, MD: A lot of fun doing it, music is such a great escape from everything else.

Mark Briesacher, MD: I suspect a lot are listening to music these days given everything that is going on. One of the things I wanted to talk with the two of you about because you have been in family medicine practice, you have a whole group of families that you have cared for ten plus, fifteen years. You have watched kids grow up and you've watched young adults become mature older adults, you've watched people retire and that is the best thing about family medicine, taking care of people over time.

Karyn Springer, MD: Yes, definitely. I think I have my first high school graduate from babies that I delivered.

Mark Milligan, MD: I have several of those, I have ones that have gotten married and it's just incredible to see that much time has gone by, 21 years.

Karyn Springer, MD: When they start driving themselves to your office, it's a little bit weird. "Where are your parents?" "Oh I can drive myself!"

Mark Briesacher, MD: And this is a little bit familiar to me as a pediatrician. When you start to get the wedding invitations and the graduations and the mission physicals where it’s like, oh my gosh, this young man or woman is ready to take on this big next step in their life.

The best thing about our jobs, I would submit, is that we get to see our friends all day long.

Mark Milligan, MD: That's so funny you say that because just the other day someone said, how long are you going to practice? I said, “I don't know, I'm not thinking of retiring at all, I love what I do.” I truly love what I do. What other job do you get to go and see 20 plus people a day that each one of them you know who they are, you know their family. I know their names and I know the medical history but I also know the tough times they have gone through, the wonderful times they have gone through, we have a history and one of the things I have to do is keep myself from just chatting and talking too long. I am trying to catch up here.

I get to do that all day. There are people I get to see at the grocery store or the bank or whatever and its really nice.

Karyn Springer, MD: It's a very special and unique connection with them, absolutely.

To have gone through the good times, the bad times, it's very special.

Mark Briesacher, MD: I would always get nervous when someone’s dad would bring the kids in and we would spend 20 minutes talking about football or baseball or hunting or cars and finally I look and I realize people are waiting and I said, “What do we need to talk about, what list do you have today so neither of us are in trouble when you get home?”

Mark Milligan, MD: It's so true, and you get to do that all day long; it's enjoyable for me.

Mark Briesacher, MD: We have seen a lot of change over our careers. I started on paper in terms of charting, Mark you probably did too. Were you on paper too Karen?

Karyn Springer, MD: Paper/dictation

Mark Briesacher, MD: Of course, since, we are on our third electronic health record, and we have seen that the big change that is related to and impacting our organization now is this idea that we have not only episodes of care we have to manage. So someone who fractures a wrist or has a laceration that needs to be repaired or has pneumonia. We also have a population of people, so we might have 500 or 800 patients on Medicare in a family medical practice that are in an ACO, an accountable care organization or on Medicare Advantage. And we actually have to manage that group of people over time within a pre-paid/capitated value based environment.

I'm wondering if you could talk about how in your practices, you balance two those demands of caring for people, doing preventive care and keeping them healthy, providing same day episodic care as well as managing a population of people who are part of an ACO, part of Medicare Advantage.

Karyn Springer, MD: The first thing that comes to mind is it is not just me managing them. It is absolutely a team, and I think that is one of the biggest differences probably as medicine has evolved is the concept of it's not just a doctor who is responsible for the patient or a PC, it really is a team. I would not be able to do it without my team, my team extends to my medical assistant who I talk to every day, "Hey this person needs this, make sure you do this." To my care manager to my health advocate, and I think we have a greater opportunity to expand the team to really be successful.

That's the first thing I would think is a big change, and that it's not me who's just managing. I definitely would not be able to do it without all my support. I'm sure you feel the same way Mark.

Mark Milligan, MD: I've absolutely felt the same way, and that's why it hasn't felt completely overwhelming because, if all that was just dropped on me and I was responsible for all...

Karyn Springer, MD: For all those reports and all those numbers?

Mark Milligan, MD: You couldn't do it. I remember even years and years ago, talk to my MA, and we would sit down and talk about the day and everything and emphasizing, “I consider you part of my team. I can't do this without you being invested in it.” I never felt that my MA's come in and punch in and punch out. They have never had that mentality. The idea is we are here to take care of patients and do a good job and at the end of the day you can look back and say everything is tucked, everything is okay and we did a good job, that was a good day. So that's been really good.

The other thing I was thinking about when you were talking about the change, the evolution of change and going back from the paper charts until now and the different ways we see patients. At every step it was a little bit daunting or a little bit scary to move to the next level, and then I saw how we responded to that, then that became my new comfort level and I really liked that. Then the next thing is coming down the pike and thinking oh no, it's going to be a little scary and then a response again. We get together as a group, as a big team and we come up with our plan, how are we going to do this. Not only respond, but actually act, proactively. And that has been exciting, because it's not stagnant, we continue to evolve and get better and always at the center of it is how can we take our patients better, how can we take care of our patients better.

Mark Briesacher, MD: So I heard a couple of leadership competencies in both your responses that I think are really important. The first is the selflessness of your leadership role. The first things you mentioned was the team, and so you are the team leader. Mark, your comment about talking to your medical assistant about how we're working together and this is our practice. That is how we would talk about it, because there isn't any way we could do this all by ourselves. The second thing was this idea that change is continuous. When you are a learning organization, a leading healthcare organization. When you are one of the best medical groups in the country who are totally committed for caring for people, our patients, consumers, families, everyone in our communities then you are raising your hand and saying "I am for change" because I am always improving and I am doing so because our patients deserve that. I think that is very commendable of the two of you.

I would submit this is actually emblematic of all of our caregivers as we think about them across the medical group.

Karyn Springer, MD: As Mark said, changes can be scary and each time as we get comfortable, we think, “Oh my goodness, can we go to the next step?” But we had to realize just like you said, in order for us to still be on the forefront, other organizations are changing too, and if we were to be comfortable, then we wouldn't be taking the best care of our patients. We wouldn't have the experience, the safety, the clinical quality that we have today and will hopefully continue to have today because we are willing to make those difficult changes. Sometimes difficult, sometimes easy.

Mark Briesacher, MD: So one thing I am wondering about, we have talked a little bit about this with our board, is the idea that there are new competitors out there. There are groups of family docs and internists getting together, and the only thing they are doing is urgent care. They come into a city in Utah and set up an urgent care shop, and we have a new competitor, and that's just what they are focused on.

Then there could be another group of family medicine docs and internists, social workers that get together and all they do is take care of patients on Medicare. So there is this phenomenon of almost a sub-specialization or what I have heard some people describe as hyper-segmentation of primary care. We have talked about as a group, about the need to be internally disruptive and go beyond just incremental change and be prepared and respond to these new competitors that are all around us in the surrounding states and Utah today.

What do you think that some of the key things are that we need to double down on as family medicine leaders that will keep the group well positioned on the front foot and leading out with respect on how to best care for people?

Mark Milligan, MD: One of the most important things is going to be access. Not the only thing but it's important because if we aren't available to care for patients, then they are going to have to seek care wherever they can find it. As I have heard it said, patients are comparing the quality of the care or access to another doctor’s office, they are comparing it to how fast they can get something online or anything else. We now have to look at the world around us and say this is what patients want and expect. In a lot of ways, that can lead to really good care because we are now seeing them when the event is happening. I'd rather have them seen in our system where we know what their medical history is and we can take care of them better than some place that just threw up a shingle on the side of the road. But we have to adapt and make ourselves available, and if we don't do that, other people come in to carve out that niche.

Mark Briesacher, MD: I know that a couple of clinics in your area, Layton and Ogden, they have actually led out on things such as allowing patients to schedule appointments online without calling the office. Layton is probably, you guys are probably implementing that.

Mark Milligan, MD: We just started doing that ourselves, and so it’s already working and patients like it. I was trying to buy movie tickets the other day—just got online and got my movie tickets.

Mark Briesacher, MD: And you got to choose your seat too right?

Mark Milligan, MD: Yeah, absolutely. Chose my own seat, really nice, right? Patients are used to that, and why can't I do that with my doctor’s office. Again, part of that is a little scary— they are going to make five appointments in a row and it turns out that isn't the case. They want good care and we want them to have good care.

Mark Briesacher, MD: There is another clinic just down the road from you and they have been helping us with video visits. What do the two of you think of about the role of video visits going forward for family docs?

Karyn Springer, MD: Like Mark said, I think technology is really where we are going to have to go for a lot of care. We look at the segments and society that have changed and one that has changed the least is probably healthcare. In terms of how we access care and how we provide care, I'm actually pretty excited to see how we can use telehealth and video visits and technology to expand our ability to care for people. I am involved with some Live Well efforts down in our area, and we are really looking to see how we can get people living well if they can't come in to meet with a dietician? Can we actually broadcast her teaching a class, or can we have an app that kind of reminds them of, “Hey! Did you exercise today?” And how can we connect those dots for those people on technology and the way they are used to getting it for everything else, besides healthcare.

Mark Milligan, MD: Always as we do this and move forward is keeping with quality care, we don't give up those standards. Now this all started for me many years ago before this (and this is when I watched Star Trek). Bones was communicating and seeing them online, he has some type of scanner. I wanted to always know, “What was a tricorder?”

Karyn Springer, MD: So we should just have followed Trek?

Mark Milligan, MD: If we had just followed Star Trek years ago, we'd be miles ahead of the game now.

But knowing Intermountain and the way we approach things, we are never going to sacrifice quality. We will do it the right way, and not everybody always does that. But Intermountain: this is safety, quality, all the fundamentals of extraordinary care, and they still apply whether it's a video visit or an in-person visit.

Mark Briesacher, MD: Patients first, design around them.

I've been thinking about how important it is that we have really strong leadership, clinic-by-clinic, and we do have that today. I'm also thinking, while we can think about strategies and where the medical group needs to go, the way that we solve for how to execute on those strategies…it’s just so important that the front line teams are thinking about those solutions. They're the teams taking care of people day in and day out.

Tell me how your clinics think about ideas and create ideas on how to always be getting better. Your two clinics really are some of the best clinics we have in the medical group and always on the front foot. How do you guys do that?

Karyn Springer, MD: I have to say that I have great partners and when we meet together or in the hallway unofficially, it's always just, "Hey! What do you think about this?" And I think that the first thing I would say with us, is that we all have the same goal. We are aligned in what we want to achieve, and it’s not like there is one of us who's like, “I doesn't care about quality,” or, “I don't care about whatever.”

I think that is where it starts—we are all on the same page, we respect each other, we are friends, and I think that's important to have that relationship beyond just a working relationship. So when we come to gather for, "Okay…what can we do better?" It's literally just like our last PPC meeting, one of my partners said, "Hey, we have all those reports and I can't figure out when they come and when I'm supposed to look at them." And so I had my care manager put together a calendar of where ... you think that's good idea? Awesome. And so it is constantly just looking for things we can share to do better. "Hey, did you hear about not ordering this, or did you hear about how I can do this here."

I think it comes down to those relationships really, to start off with, and then our alignment on what we want to achieve in taking care of our patients.

Mark Milligan, MD: A lot of times it’s interesting, we have our monthly doc meeting—it's mostly primary care—we are in there talking, no one is afraid to speak up. This is what I like because if someone says something and they are kind of miffed and everything, then everyone will kind of say, “Well, okay, we will chill and figure it out.” But no one is afraid to speak up. If that is how they feel, we want to hear about it. But mostly it is good suggestions, people come up with great suggestions. Someone may say, “I'm frustrated. I can't get my patients in this way or that way,” or some problem. Then someone says, “Well, you know what I did when that happened?” and we do those kind of ideas. Our clinic manager is really good about saying we should implement a process for that and see if we can improve that. And then we watch it in the next month so we can say, “How did that go?” and, “Yeah, it’s been going really good.” Sometimes they go up the chain.

Karyn Springer, MD: It starts at that granular level.

Mark Milligan, MD: Absolutely. And I think of how the clinic is, and I feel really warm and fuzzy going to work because I am working with these people I really, really like. It’s a good place and within these four walls; I really like it. And I think that's kind of a mini One Intermountain—it’s right there and we work together really well. If I want to get something done, I say something and we try it out and see if it works. It’s kind of a place where those ideas grow.

Karyn Springer, MD: I think that's what's so exciting about One Intermountain in general because that granular level at our clinics, I think there is going to be a great structure in terms of bringing that forward and really sharing ideas. I hope as a family medicine service line throughout Intermountain, and that is so exciting because we can gain from other people’s experiences.

Mark Milligan, MD: Think of the potential in that, this medical group of these amazing providers that have this wealth of knowledge and experience, if we can all figure out how to get all the gears to line up and work really smoothly. That’s what we want here at Intermountain. That doesn't feel like just an idea, or theoretical, I think it's something that we can work toward.

Mark Briesacher, MD: I agree, and I think that this is a great example of all of us working together can actually move faster. This is our response to those competitive threats, these disruptions that are out there, and that is to move fast, share ideas, have direct conversations about how to solve tough problems, be willing to try new things and always with patients first and foremost, designing things around them.

I want the two of you to know that I have so much trust in your leadership within the clinics and the leadership you show on our board and this trust extends to every clinical leader in our family medicine clinics across the medical group and other specialties as well. It is going to be at that level: the physician, clinic leader, the clinic manager, the nursing leader for that group, that's the leadership triad, that's the leadership group that is going to come up with these solutions that are going to advance our ability to provide the safest, the best care possible within a healing experience. Providing the access you talked about Mark, it's all going to be great for our patients and their families.

I can't thank you enough for being here today and sharing what you do and how you do it, and I am really looking forward to what the future is going to bring for us.

Mark Milligan, MD: Thanks for having us.

Karyn Springer, MD: Yes, thanks so much.