Naji Gehchan: Hello, leaders of the world. Welcome to spread love in organizations, the podcast for purpose-driven healthcare leaders, striving to make life better around the world by leading their teams with genuine care, servant leadership, and love.
I am Naji, your host for this podcast, joined today by Dr Robert Bruce Associate Chief of Clinical Affairs at Boston University School of Medicine, and Director of Primary Care at Boston Medical Center (BMC). Prior to those roles, Robert transformed healthcare in the New Haven community focusing in the largest health center in new haven on quality and value based care which resulted in significant savings for CT Medicaid and the community. Doug was also Chief of Medicine at Cornell Scott-Hill Health Center and Associate Clinical Professor of Medicine at Yale University. He is a global expert in substance use disorders in people with HIV and hepatitis C. He has published widely on the topic of substance use disorders and HIV. He has provided technical assistance to CDC, NIH, and the United Nations.
Doug – I am so honored and humbled to have you with me today!
I would love to hear your personal story, from childhood to becoming an expert in HIV land hepatitis C living with and helping some of the most touched countries by those pandemics. What defined your journey and the incredible leader and physician you are today?
Doug Bruce: That’s a great question.
So, um, I grew up in the Cambridge kind of Boston area as a little kid, and I grew up and had lots of pulmonary problems actually. So I had like lots of asthma and what’s in and outta emergency room all the time. And so. I had some really good pediatricians and some not so nice pediatricians. And so at an early age, I thought, you know what?
I wanna be a doctor. I wanna be, I wanna be one of the nice ones but I wanna be able to help people. I want to be able to bring, um, joint and comfort. I, I realized that. What stood out in my mind as a child was not, oh, this doctor has more knowledge than that doctor. Right? It was more just, oh, this doctor seems to care about me.
Now, this one seems like I’m a widget. Um, I wouldn’t have said widget when I was a kid it was kind of the feeling. So I, uh, for a long time, felt like. I really wanted to be in healthcare. Um, my faith is really important to me and I realized when I was working in the public hospital system. So I, I went to the university of Texas Southwestern med school in Dallas.
And I worked at Parkland Memorial hospital, which is a big county hospital system. And I was taking care of marginalized populations of groups of people. Kind of, you might think of were forgotten by the system and began at that time, it was the aids epidemic was working with people with HIV, people, with substance use disorders and, uh, saw all kinds of things that, um, I felt like there were great inequities and great trials and tribulations that people were facing.
And that one of the jobs of being a physician was to be an educator, but also an. And so after I finished my training in Dallas, I went to Yale university and did a graduate degree in philosophical theology, um, because I wanted to read widely and think, and be very reflective about the care of those groups of people.
And then started working with the LH program and providing street level care for substance users and people with. And from that began developing programs and then working internationally with marginalized populations to try and systematically make things better for people who may not be able to advocate for the.
Naji: You, you have served, uh, Doug in countries hit hard in moments where few innovations were even existent for those diseases to treat those patients. Can you share with us your experience stories, learning that you take with you today leading in healthcare systems in the
Doug Bruce: United States? Yeah. So, um, I guess two, two things stand out.
One. I spent a fair amount of time going back and forth to Ukraine and what’s happening. There is a tragedy when I was in Ukraine. Uh, one of the trials that we faced was how siloed healthcare is, and we know that healthcare can be siloed in many countries. And so my time in Ukraine taught me that creative ways to try and overcome.
Seemingly impossible silos. So, uh, just concretely, for example, in Ukraine, if you take care of drug addiction, you’re an oncologist and you’re not allowed to prescribe medications or offer any treatments outside of your narrow scope. So like unlike in America, right? I’m not a psychiatrist, but I legally could prescribe psychiatric medications and Ukraine.
If you’re an oncologist, you’re not describe. Treatment for tuberculosis, even if your patient has tuberculosis, you have to get a special doctor, APH physiatrist who will do that. And then that person is divided between those who do it on the inpatient system and those who do it on the outpatient system.
So I kind of learned in that environment, just the critical need to begin asking questions to talk, not just to government officials or healthcare officials, but stakeholders. And, and I had known that in the, in the. Aids epidemic stays in the nineties and the importance of stakeholders, um, and importance of voice and people giving people agency and voice.
I think what I learned differently was also, um, sometimes the way to get to the truth is you have to just talk to so many different people. And that’s what blew my mind when I was in Ukraine. I didn’t understand the limitations and I. Because people were not forthcoming. I represented a government or I represented a university and people felt that they had to answer me a certain way, but when I would go talk to drug users or people with HIV and community, people were very forthcoming.
They’re like, ah, no, this doesn’t work. Or this is the real problem. Um, and like a classic example was when I was in hair song Ukraine, and we were just talking about like TB adherence rates and it was just, it was really difficult to understand. Like what the problem was because on one hand, like there are no problems, but eventually we got to the realization of, oh wait, you can just walk up to the pharmacy at the TB hospital and by part of a TB regimen.
So what, what we found out was like, if you were a substance user, you would go and get admitted to the hospital. You’d had no treatment for your heroin problem. So you got sick, which meant that you left, but you had started some treat. Your new treatment was important. So after you left, you could go to the pharmacy, but TV treatment was for medicines.
So you can’t afford four medicines, you buy one medicine. And so that helps you feel better until you get drug resistance. And so it was kind of this systematic problem, but it was very difficult to get at it through one lens. And so I think that was one thing that was really important to me. And I carried that with me when I went to Tanza.
And the need for stakeholders. So, um, an example of this was, um, so in Tanzania there’s a big heroin epidemic. That’s kind of really fed into the HIV epidemic. And we had a situation where those most at risk for HIV were female sex workers who also injection drug users. We had very, very high rates like in the survey samples that they had done, like over half of the women had HIV.
So we’re trying to get them into treatment on meds. You. But when you looked at the clinics, the clinics were mostly men that were providing services. And so what did we do? We had to go out and actually meet with the women and talk to them and find out like what’s going on. And they brought up just very logical reason, right?
Like what the clinic doesn’t have the hours that are convenient for me. Right. Cause the con the clinic had morning hours. The women were sleeping cuz they’d been up all. Uh, with their trade over, over the evening and using, using substances. So we had to think about, well, how do we lower the threshold so that women can get in?
How do we create a safer environment? What do we do with the men that are loitering around? How do we create an environment that’s, um, safer women. And, and that was based on the feedback from, from the women.
Naji: Uh, those are, those are powerful examples that, that you’ve, uh, led. Uh, so how, how do you ensure like this curiosity, but also this need actually to go on the field, understand what’s going on and bringing it back and change the system because you practically had to change systems to make this work for patients.
Doug Bruce: Yeah. So, um, I mean, I. You have to tailor it. Right. But to, to your point, just, just because someone recognizes the need doesn’t mean that they’re willing to help. I mean, an example of this is, um, we were showing that the tuberculosis rates among the patients in that first drug treatment program in Tanzania were very, very high.
It was not surprising. It was one of those things. You know that there’s a high probability that, that this is gonna be the case. Substance users are using drugs together. They’re in closed environments, inside poor ventilation, HIV increases your risk of tuberculosis. So the probability is that there’s gonna be TB among the substance users.
The there was no active program to search for TB. So one of the early programs we did intense and after we set up the drug treatment program was to check for HIV, offer HIV therapy, but then it was to start trying to be active in, uh, searching for tuberculosis. And so a, a student of mine went out there and, uh, started doing active case finding and the teams in Tanzania supported this.
So they were all really interested in. And part of the team’s interest, as you can imagine, was they didn’t want to get TB. And so, um, it was kind of playing off the enlightened self interest of this is a real material patient concern, but if there are high rates of this, this is a real material concern for all of the healthcare workers in that environment.
Cause. I mean, we didn’t have, they weren’t in 90 fives floating around for everybody to wear for TV prevention. Right? The main TV prevention is great ventilation, open windows, staying outside, um, where UV light kills it. So that program found that there were high rates of TVB like, not as high as south African mines, but like 20 times higher than the national average of tens.
So very high rates and eventually. You know, it’s not surprising, right? So you change your infection, protocol, infection, prevention protocols, you have better ventilation yet. Don’t put people in isolated environment. And, uh, eventually actually the TB program from the university hospital system in Tanzania started spending time taking care of patients.
And so it changed the system. But in this case, it was playing off on that enlightened self interest, which also paired with the patient. But then we tried to get, you know, external funding from a separate government agency that for all intensive purposes, you would’ve thought would want to fund this. Cuz their enlightened self interest would be like, oh, like you can get credit for this, but they didn’t wanna get involved because a different agency was funding.
The, the larger work that we were doing. And so they were worried about, they never said this, but it became apparent that they were more concerned about. Uh, who got credit for the activity, then the activity itself, which is very disappointing. So I wasn’t able to, to change them. They’re they’re much bigger than me.
Naji: well, yeah. And it touches to all those lenses. We, you know, we both learned in, in class mm-hmm um, the, obviously this is a huge impact that you had in, uh, again, in countries with. Tremendous need and in moment of crisis, uh, obviously in those countries, uh, I would love to get another leadership learning from you as you led teams there.
So you had students, you had physicians who were working with you, uh, and it’s kind of potentially also relatable to so many folks. And you went through the COVID pandemic yourself as a, as a healthcare provider. How do you lead teams in such moment? High pressure, attention, uh, emotional, uh, struggle and really life threatening diseases that you’re dealing
Doug Bruce: with.
That’s a great question. So I think probably the most important thing that I did in Tanzania, um, was to come in, in humility and say to the teams, cause like I’m a guy from the United States coming in. And I’m, I’m hoisted upon the people and people there, and they’re, they’re smart physicians there in Tanzania.
And so it can be very, uh, off putting, if you are, you know, a academic in the local university there in Tanzania, and some guy shows up from the west and says, I know more than you do. Right. So what I had to come in initially in the, even in the beginning meetings to say, I’m only here because I’ve done this before.
I have a body of knowledge. And so my job is to, to impart that knowledge and to work with you, but you have to figure out how this is going to be in contextualize in Tanzania. I’m not Tanza, I don’t know the local politics. I don’t know how to do this here, but we’re gonna work together to be successful.
And so I told them from the outset. I, there will be a day when I don’t come to Tanzania anymore because you won’t need me because you will be the experts. And so I think that resonated very strongly with them because they had been through, as you can imagine, a series of kind of us government funded activities, where people come in, kind of tell people what to do and set it up.
And, and it’s not as value driven from the, the people there. And. What I saw in my role as was just, I’m kind of your consultant, I’m your, your information person. And I’m really here to support the team, but you’re gonna actually contextualize it. And so a lot of that then became more about empowerment, more about working with the leaders to say, um, so like kind of an example, They were very worried about overdosing patients, which is a, a legitimate concern.
This was a methadone program in Dar Sal lump Tanzania. So they are keeping the doses really low. And so what that, what that happens is if you don’t give somebody adequate replacement therapy, they continue to use heroin, engage in risk, but they were afraid to go up on the dose because they thought, well, if I give the person more methadone and the person continues to use heroin, they can.
Which kind of is a logical fear, but the reality is as you go up on the methadone dose, they go down on the heroin dose. So, so I said to them, look, you all the very smart people. Why don’t you, um, just set up a small mini trial, just take some proportion of the patients, go up on their doses and see what happens.
You don’t have to make it a clinic-wide policy, but just use it as an opportunity to learn. So they did. Right. And this is this, I’m not like announcing this. I mean, this is just like private conversations with people and they did that. They went up on doses. Patients stopped using heroin and they were like, this is amazing.
And then the next thing I know, they have generalized that throughout the system and then they’re really dosing patient. But again, it was, it wasn’t about me coming in saying, this is what you have to do. It was. Let’s have a conversation and let’s talk about our options and why don’t you consider this kind of a pilot project.
And so I think humility is the most important thing that I learned in interacting, especially in international projects, because so often people are coming in again and just kind of telling people what to do, and then that’s so devaluing. Right. But as I talked to them and said, You’re the experts. How would, how do you, how do we do this intensity?
Like, what are we facing? How do we address this? It was, I think it was very empowering. They eventually set up training programs there where they were training additional physicians and, and who are now leading other programs, which was exciting. Um, but that’s something that I then took back to Boston and, and to other places of just, um, never underestimate the information and the power of the person that you’re meeting.
Regardless of education, regardless of position, they have something to teach you. And, and that, by valuing that person and partnering with that person, you can make a lot of change, more change than you thought you could. And it’s a great
Naji: pivot to my next question. You talked about humidity empowerment.
These are really strong, strong words. As a leader. In the last years, you’ve been focusing on innovation, operations, optimization, practice transformation, like all those large change management projects in academic, uh, medical practices in the us. So what is the main challenge you’re facing today and how do you lead through those large organizational
Doug Bruce: changes?
Yeah, inertia is a huge problem. I’m just amazed at how physicians, nurses, medical, assistant administrators really almost feel like the system can’t change, or if the system can change, they view it as, you know, one or 2% on the margins. Um, they view it through the current lens that they’re that’s, they’re passionate about volume value.
Um, Finishing my charting, right. Not spending the evening doing that. And so I’ve found it challenging to kind of help people understand that, wait, should you reconsider the entire paradigm here? You’re like, you’re living in this soup in this swimming pool, whatever you’re in. Maybe you should get out of it.
Like maybe we would need to completely rethink things. Um, and so some of that has then. You know, as I always do in a new environment, you spend a whole lot of time just talking to people, surveying the faculty, getting feedback, and trying to create an open door policy. And then also trying to help people understand.
Look, I’m not gonna take it personally, if you come and tell me that the system is dumb and it’s broken, like I’m, I’m, that’s fine. I want information and I want information so that we can make it better. But I would say like, inertia is a big thing and, and the pandemic. In many ways, because the pandemic was this push into the lives of people where people felt disempowered, they felt hopeless.
Like there’s this external factor and I can’t fight against it. And I think certainly where I’m working now, people have transferred that into their work environment. Some that, um, you know, my clinic got flipped from, in person to telehealth. I didn’t have control over that or. Alerts keep coming up in the electronic health record.
And I can’t control that. Or, and so there’s this sense that I’m powerless and because I’m powerless, I’m not really engaged with change management because I’m kind of hopeless about change. And so a fair amount of what I’ve been trying to do is find some small wins to show people that change is possible, but change is possible when we work together, change is not really possible.
Doug Bruce by himself trying to make change. Right. That’s completely ineffective it’s as we work together and come together that we can make change. Um, but fighting against inertia has been painful.
Naji: And this is a very interesting insight because as you said, pandemic has challenged all of us, right? And many would think that it challenged us in a way to change that now will be sustainable change, right?
Like from work from home and the hospitals, all telemedicine the speed of developing drugs, et cetera. But I’m hearing from you, the state of mind of healthcare providers today is not that like I heard. Hopelessness. We’re not powerful enough to make those changes. Where, why do you think that as we know, there is a huge mental toll on, on healthcare providers.
And many times I’ve shared it before we applauded them in the beginning of the pandemic, but actually didn’t change much of the, the struggle they go through, uh, after a couple of months. Right. So what do you think is happening and how can we do it as healthcare leaders across the different, uh, healthcare industries?
Doug Bruce: Yeah. Well, I, I think the, one of the things that I’ve been trying to do is actually apply some of those lessons that I learned in Tanzania and into academic health centers, because, um, academic, medicine’s a very hierarchical system where people don’t feel like they have voice or agency, um, and, and promotion systems and things can be somewhat opaque.
And so trying to give people an opportunity. And so some of that is. And this is seemingly silly, but I think people have found great value in it is personally replying to the emails that people send me. Right? Like I’ve, I’ve, I’ve heard what you said, you know, or taking time to you have a question. Well, let’s set up a call, let’s have a conversation about this, you know, do you wanna mean person?
Do you wanna meet on zoom again? It’s it’s really trying to be responsive. And then to be honest, I mean, the thing that I’ve been trying to tell people is like, look, I’m I’m, I’m not gonna lie to you about this. I’m gonna just tell you where it is and it could be. Your issue is completely legitimate.
Unfortunately, like right now we don’t have resources to address it, or we don’t, we can’t address it. We don’t have the technology or it could be like, I’ve got this fire over here and we have to address this fire before we can do this. And the faculty, I think at least in the feedback they’ve given me is that they’ve been very appreciative of the transparency and the honesty, um, because that builds trust.
And so then when there’s some trust and then you. We can do this. Like, Hey, like we can, like, there’s a pathway forward. We can make this change and make it happen. Well, people start to say, well, Doug’s been honest before. Maybe he’s being honest about this. Maybe he’s not just saying this, like people have said in the past to try and motivate us.
So we see some more patience. Um, so I think building trust through transparency and honesty is really important. If we’re gonna start trying to help healthcare providers. Get out of some of that inertia and hopelessness and feeling that they don’t have voice and they don’t have power. And so we have to create opportunities for voice and agency and we have to listen to that.
And then we have to be responsive to that.
I love that.
Naji: Uh, I, I would give you one word and I would love to get your
Doug Bruce: reaction to it. So the first
Naji: word is leadership.
Doug Bruce: I guess when I think of leaders, I think about people who get on the front line and work with and like, or in the, in the middle of the battle. Right. I don’t think of leadership as detached from what’s happening. Um, the, the most success I’ve had in leadership has been. On the front line, learning from people, teaching people and changing the system there.
I think increasingly when I think of innovation, I think I would say I used to think of that as change, like modify the current system. And I, I think of that now as creativity I think more and more of innovation. What’s a better system. Like just what’s a completely better system. And so I would say I’m learning in that space again, having a breadth of people speak into that is really important because of the, the realization that I could say the current system is bad.
Let’s make a new system, but it shouldn’t. My new system, it should be our new system. And so well, who are the, our, and so often, like the physicians in the practice will say, what’s, what’d the doc say? You know? Well, what, what about the nurse practitioners and the PAs? What about the nurses? What about the medical assistants?
What about the front desk staff? What about the stakeholders? What about the patients who are the actual people who are coming right? And so the more that we branch that out and the more that we give agency and voice, I think the more we can be truly innovative and have something totally different, um, which is what I’m now thinking more about as the word innovation, just making it completely different and better intellectual
And it comes from a debate we had
Doug Bruce: Yeah, I think so. I, I really do believe that you need to protect intellectual property. So I’ve changed in my view of this, right? Like I, I was in the, probably more supportive of act up and like, Get meds to the world. I still believe that we need to find ways that we can get medication across the globe, to everyone who leaves it.
Um, the, the very reason that we did a methadone clinic in Tanzania versus anything else was because, um, it’s the cheapest thing to do. It’s also the most effective, which is kind of rare that the cheapest is the most effective, but it was incredibly effective, but because it was cheap, we could treat more people.
And, you know, in public health interventions, it’s really about treating large numbers of people. If you’re going to make a difference, right? If, if we only vaccinated 10% of America against COVID, we really wouldn’t be having the kind of successes that we’re having now. So public health interventions, especially with infectious diseases require large scale intervention.
I think that if we don’t protect intellectual property, people will not be innovative. They will not create completely new drugs. They will not create completely new solutions. I mean, I’m amazed when I started taking care of people with HIV, they were fists of pills that were incredibly toxic and horrible life limiting side effects to now, now, today, like, I mean, this is crazy to me.
It’s easier to treat HIV than high blood pressure and. Like I, if you had asked me in the nineties, in the middle of the aids epidemic, you know, someday HIV will be easier to treat than diabetes. I would’ve said you’re nuts. Like that’s just not gonna happen, but it happened because people, because let’s be honest, right.
There was a profit motive in, in doing that the same with hepatitis C. Like I never thought that we would be curing people as easily as we can now with hepatitis C treatment and. I want to preserve the intellectual property that helps foster innovation for companies to make a profit, because that’s why they’re innovating in the first place.
I just wanna find a way where we can, that those medications don’t just stay in rich countries. And then the patients that I care for in, in other nations of the world, who are people too, and who have I. Dignity as people and rights to good healthcare that they can’t access it just because they were born in a foreign country.
Right. That just doesn’t seem right to me. Um, but I do fear that if we just do away with IP in these things, or we fight against them, then people will say, well, why, you know, we’ll invest our money in real estate or something. And I don’t want, I want people to continue to invest in developing great medications, especially when there are some serious diseases still in the.
That we need people to be innovative about. I mean, malaria, for example. Yeah. What about
Naji: spread love in organizations?
Doug Bruce: Well, I think that, I mean, that kind of goes to everything that we’ve been talking about. Right. Um, I, you know, one of the things I, I tell healthcare providers who can be so serious sometimes , I’m like, you know, if all we do when patients come is tell patient.
How they failed in everything. They failed to lose weight. They failed to take the medicines. They failed to like, go get it. Just whatever, like who wants to come see anybody? That’s that negative? Who wants to come see the healthcare provider? Who’s like, yeah, you, you failed come back. Um, and my own life.
Right? So my, my doctor told me one that, um, cuz I was like, I don’t wanna exercise. Why don’t you just give me a statin for my Cho. And like the guy looked at me and was like, you’re a smart guy. Figure it out. Like just go exercise. And I didn’t go see him for a year because I was like, I wasn’t exercising.
And then I like exercised two weeks before I see him. So I could answer the question and be like, yeah, I’m exercising. And he didn’t even ask me. I was so upset. I was like, really, but that’s not necessarily a productive healthcare relationship. And so when I think of spreading love, I think of spreading love, both among staff.
So one of the things that I do often is I try to remind every member of the staff, their vital importance. So I’ll tell the front desk staff, like you’re the first point of contact when people walk into the clinic, like your role is incredibly important because that’s gonna set the tone for the rest of the visit.
If I’m mad after the front desk, I’m gonna be mad when I talk to their medical assistant, I’ll be mad when I talk to the nurse. I’m mad when I talk to the doctor. So, and then empowering medical assistants, like you are getting a proper blood pressure as like real material, healthcare consequences, like your role’s really important.
And so I think part of spreading love is helping people know that they are valued and that they’re not just parts of a machine and that we, I can flip a switch and easily replace you. It’s like, no, no. Like you are bringing you to work today. And you are valuable and you are important and what you bring is important.
And so I think as people feel that value as they feel that like coming to work’s really important, I like, I need to go to work today. Well, why? Cause I’m really important that then spreads to patients, right? If I’m really happy and experiencing joy in my job, because people hear value and care about me, I spread that to patient and that’s infectious.
I mean, I like infectious disease. Right. But like it’s really infectious. And so I think we just need more and more to do that. And it just starts with saying you have dignity as a person, and I need to treat you with dignity. And as I do that, I’m spreading well,
Naji: I love that Doug. And, you know, I, I thought a lot and you kind of touched on the four letters that I sometimes use with love.
It’s listen, observe value, and empower you. You literally talked about all of that. Thank you so much for those amazing examples. Any final word of wisdom for healthcare leaders
Doug Bruce: around the word?
Uh, I would say be creative, be a listener and be humble. The, you know, I I’ve had, um, high school educated substance users, um, teach me things. I’ve had people with multiple doctorate teach me things.
Naji Gehchan: Thank you all for listening to Spread Love in Organizations podcast. Drop us a review on your preferred podcast platform
Follow us on LinkedIn and connect with us on spreadloveio.com. We’re eager to hear your thoughts and feedback. Most importantly, spread love in your organizations and spread the word around you to inspire others and amplify this movement, our world so desperately needs.