Episode 2: Business and Humanity in Medicine

In a career of accolades for innovation and technology, one of Dr. Ira Kirschenbaum’s greatest achievements has to do with people. After 17 years growing two orthopedic practices, he uprooted from the comforts of White Plains, New York and relocated to the South Bronx to provide care in the poorest congressional district in the nation.

Now 11 years later, Dr. Kirschenbaum has grown the team to 14 surgeons and 70 employees, seeing more than 430,000 patients a year. His lessons about recruiting, innovation, and balancing the business of healthcare with the humanity of their mission are priceless.

At P3 Inbound, we’ve worked closely with Dr. Kirschenbaum to help build a physician referral system called Referral Pad, using Dr. Kirschenbaum’s expertise on the business of medicine. This is one of the many tools he has in place to keep his practice running smoothly and get patients the help they need in an efficient manner.

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Full Transcript

Announcer: It’s time to think differently about healthcare. But how do we keep up? The days of yesterday’s medicine are long gone and we’re left trying to figure out where to go from here. With all the talk about politics and technology, it could be easy to forget that healthcare is still all about humans. And many of those humans have unbelievable stories to tell. Here, we leave the policy debates to the other guys and focus instead on the people and ideas that are changing the way we address our health. It’s time to navigate the new landscape of healthcare together and hear some amazing stories along the way. Ready for a breath of fresh air? It’s time for your paradigm shift.

Michael: Welcome to the “Paradigm Shift of Healthcare” and thank you for listening. I’m Michael Roberts with my co-host, Scott Zeitzer. On today’s episode, we’re talking to Dr. Ira Kirschenbaum, Chairman for the Department of Orthopaedics at the BronxCare Health System.

Scott, I know you and Dr. Kirschenbaum go way back on this one.

Scott: Yeah. I was trying to think about that. Ira, it could be close to 30 years, if I’m not mistaken. Is that right? Am I right?

Ira: Yeah. It was just at the end of the Paleolithic era, maybe Neanderthal era.

Scott: Yeah, that’s quite a while. And the reason I wanted to get you on this podcast is that you are an interesting person from many perspectives, but this is a unique perspective that you are a successful orthopedic surgeon in White Plains, which is a very nice neighborhood, a suburb of New York City. I know you were successful because I was your orthopedic rep. I saw that you were busy. You were doing lots of work. And then you decided to go down to the South Bronx which, if I’m not mistaken, Ira, it’s the poorest congressional district in the United States.

Ira: Yeah, the 15th congressional district is the most indigent and poorest congressional district in the nation.

Scott: And you went from White Plains…

Ira: And upper East Side, by the way, where I also was briefly at Lenox Hill.

Scott: Yeah. You’re right. I forgot about that. You’re absolutely right. So, you know, upper…very fancy, you’re in Manhattan, Westchester, you were doing very well as a private orthopod, and you decided to go to Bronx-Lebanon. And you really, I mean, quite frankly, you turned things around there, to be perfectly frank. I just wanted to get your, kind of, thoughts about why you went there. What led you there, basically?

Ira: Well, it’s really interesting. I mean, first of all, I have always done a variety of ventures in my entire career. There is no question that I’ve had an interesting tour of duty. I originally started my career at Kaiser Permanente, where I was there for…working for the orthopedic department as an employee and then a contract employee for almost 10 years, and did a lot of work in resource management as well as orthopedics there and learned a lot of business there.

So I always like to grow things, I like to do things. But I also feel that I was now entering my 17th year in private practice, talking about being about 50 years old. So someone came to me, who was the head of the emergency room at BronxCare, a guy named John Coffey, and he asked me, “How do we get a guy like you at BronxCare?”

At that time, the hospital was named Bronx-Lebanon, it changed its name recently to BronxCare Health System.

And I said, “Why get a guy like me? Why don’t you just get me?” Of course, he knew I did a lot of different things, grew two different practices, I grew the Kaiser Permanente Orthopedic Department, and then I grew a private practice to over 400 cases a year in a solo joint replacement practice.

And he said, “Are you serious?”

And I said, “I must be because that just came out of my mouth.” And I really wasn’t necessarily looking. I met with the Physician Chief, I met with the COO, and I met with the CEO, Miguel Fuentes, who, we had a long discussion. He’s quite a visionary. And he presented the opportunity that they have in their hundred plus years, never had a department of orthopedics here. They really only had, essentially, locum tenens, part-time guys, people not fully committed, and there was a chance to build something.

And this was, I guess, another chance to build something. It was an opportunity to apply a lot of the principles I used both in my training, where I trained at the Rothman Institute with Dick Rothman, as well as my private practice to a community that was in need.

And a lot of people thought I was crazy. Just, “How are you going to treat the community with the same type of business plan?” And, you know, the tale of the tape was that looking back, we’re now on our 11th year, and we’ll get into this more, you’ll ask more questions about it. But, you know, it started as a business and a mission. And now, it’s that mission and business have continued.

Scott: Yeah. It’s amazing that you basically built something from part-timers to… How many people are in the department right now?

Ira: We have 14 surgeons and 70 employees.

Scott: So it’s extraordinary to build it to that. I have been up there. I’ve watched patients hug you. I’ve seen you actually speak some Spanish, which, again, that would be typical for anybody being…treating patients in the South Bronx. You better know a little Spanish. You know a little bit more than a little Spanish, which I think you taught yourself over time while you were there. Correct?

Ira: I taught myself and I have a great tutor every Sunday night. I’m fairly fluent in what I call joint replacement Spanish. And now, I have expanded into general medical Spanish. If I had to go to a restaurant in Spain or Puerto Rico, I would probably have to order a knee replacement or a hip replacement for dinner.

Scott: But otherwise, you’re gonna do fine.

Ira: But otherwise, I would have a fine meal.

Scott: So, you know, from a change at the hospital perspective, the interesting thing…so for everybody who is not into orthopedics and is listening to this podcast, Rothman Clinic is a very well-known joint replacement education center as well as a joint replacement implementation center. So great training site as well as, patients are genuinely taken very well care of. A private institution if I’m not mistaken, is that right, Ira or is it a…

Ira: This is a private, not-for-profit, non-governmental hospital.

Scott: Right. And are you talking about that being Thomas Jefferson at the Rothman Clinic or are you talking about Bronx-Lebanon?

Ira: Well, there’s two things. Jefferson is a not-for-profit, non-governmental hospital, a voluntary hospital. The Rothman Institute is for profit. They are an orthopedic group that works…partially works out of Jefferson as well as their own…they own their own ASCs and other things. In their work at Jefferson, they are a group. They are a private group that works out of there. We’re a little different at BronxCare where we are the similar type of hospital structure, but all of our doctors are employees of the hospital.

Scott: Yeah. Which is what I was gonna bring up is that you’ve got all these employees who are performing very…I mean, these are well-trained physicians. I know you’ve got a total joint surgeon, a specialist who’s from the Hospital for Special Surgery if I’m not mistaken. Am I correct?

Ira: Yeah. Now, we have two joint surgeons, one from Special Surgery, one is coming to us from just finishing a Müller Fellowship in Switzerland and having trained at Washington University. We’ve been able to recruit some very exciting top talent where people thought it was not possible. And we have…I mean, the department as a whole has about 90 to 120 peer review papers. I mean, it’s not the MayoClinic which has thousands, but if you’re at the Mayo Clinic, course, you would, of course, have to live in Rochester, Minnesota, not out here.

Scott: Nothing against the people in Rochester, Minnesota.

Ira: People in Rochester are wonderful, but living…it would be great living there I’m sure.

Scott: Yeah. There we go. But you know, if everybody really gets this, is you’ve got some very well-trained orthopedic surgeons, and you are able to attract them to what used to be, 11 years ago, a place no orthopod would consider really going to unless they, I mean, performing surgery at, unless they really kinda had to or it was like a charitable thing. Whereas now, you’ve got people trying to be a part of that department

And I guess, like, how did you attract that talent? Before we can get to how you take care of the patients, how did you attract that talent who could take great care of your patients?

Ira: At first thought, you would think that I brought them down to Special Surgery, toured them around, told them this is the place, and gave the BronxCare address afterwards. But that’s not how it worked.

So when I recruit, I sell them, I sell the recruit, the person I’m recruiting, the opportunity. And then I see who’s buying. Okay? So I’ll recruit six or eight people, some will buy what I’m selling here, the opportunity, and some, will not.

So right off the bat, the only people who would decide to come here are coming here eyes wide open. They know what they’re in for. Okay?

One of the lines I have used and a number of the alumni from this program, I call my people who have been attendees here or have moved on to something else alumni, we still all keep in touch. No one has really left without good wishes. I tell them, “You give me four years and I will give you a career. There is a unique opportunity to get busy right away, get tremendous oversight in the beginning of your training, be brought along properly as a surgeon, hone your skills extremely well.”

Keep in mind, I am already attracting top surgeons. So not only…no one’s coming here to practice. These are top surgeons, to begin with, and they understand that the opportunity is two-fold. One is they have patients who are extraordinarily appreciative of the effort and the time that they’re spending and have very advanced disease with multiple co-morbidities. So the people I attract want to treat people who need extremely high-level surgical skill. So high-level surgical skill surgeons are attracted to a place that has challenging cases.

And the second reason is there is a lot of camaraderie in the department. There’s a lot of opportunity for research, for innovation. We have interesting arrangements on how surgeons can invent things and do intellectual property and benefit from that themselves. So I have a model of innovation built into the recruitment.

And also, once you build a reputation that people have been happy here, you know, over 5, 10 years, it then…word gets around.

Scott: And that seems to be happening. Like, I noticed, like, when you first got started, you were attracting really good talent, people were getting taken care of, patients were seeing that. And that takes time, everybody, it really does. And then the word does get out. And it seems like your clinics are very busy. And I mean that from a happy perspective, not from an overworked perspective. The surgeons are happy getting that done.

Is this something that you think could be repeatable? Like, could you move that to say, I don’t know, the second poorest district? I don’t know what that is, by the way? But whatever…

Ira: It must be the zip code next to this one, I guess.

Scott: It could be.

Ira: No. The reality is it’s something I… What we tried to do was develop a reproducible, sustainable system that you can apply to Cook County in Illinois, LA County in California, you know, where Charity Hospital used to be right in New Orleans, was it?

Scott: Yeah. I was just thinking the same thing, right in our home town.

Ira: Ten percent to 15% of this country has a demographic of our community. So we figured, if we can solve this problem here, we can solve a problem for 10% to 15% of the nation.

Scott: If anyone is listening to this podcast and they do want to connect with Dr. Kirschenbaum about some of what he’s done, please, we’ll give you some information about how to get a hold of us, and we’ll be happy to relay you accordingly.

And that is why we had you on. It’s extraordinary to see. I’ve been in that clinic just on a few days and it really is something to see, just the workflow. Ira happens to be a bit of a nut on workflow. And I say that in a positive way, where he’s got a lot of systems in place. If I’m not mistaken, there’s like a series of lights on each door about who goes in, when they go in, color-coded lights. Ira and I have worked on software projects together as well as programs together. I know that you’re very systematic as well. But if anybody is interested in reaching out about that kind of stuff, believe me, I will be happy to walk you through the place.

Some of your alumni, are they going to private practice, or are they staying in this type of situation, or a little bit of both?

Ira: They’ve all done academic practices.

Scott: Interesting.

Ira: So they’ve all done hospital-based, hospital-employed. One person left because he wanted to be closer to home. One person left because he got a professorship. So it worked that way. One thing they all learned is what you talked about. We process engineer everything. There isn’t anything we don’t process map here. Every interaction is done through a classic engineering process map from when they say hello to when they go through clinic, how the surgery gets booked.

So we were so frustrated with the EMR. Not that all EMRs are terrible, they’re actually not. They’re all horrible. There is miserable, terrible, and horrible, three different things. It’s miserable to work with it. They’re terribly programmed and a horrible experience.

So we actually built our own cloud-based platform based on our process map on how we wanna function. So we, using a cloud-based, data-based platform called TrackVia, T-R-A-C-K-V-I-A. They don’t make a program, they make a platform where you could program. It’s a low-code program. I think of Microsoft access in the cloud, and we built apps for ourselves to follow patients on the floor, follow patients on the hospital, find out who’s coming to us referred from satellite clinics, what happens to those people, what are the test results of the MRI, how are they coming back, what’s the life cycle of the surgical patient. We follow them from booking all the way through six-month follow-up with this platform. We even look at the finances.

I can tell you how much revenue is generated by each surgeon each minute. I can tell you the complication rate. I can tell you the patient outcomes. I can tell you the patient satisfaction. I could tell you patient complaints. We’re very patient-centric, very high on patient-centered care. We have an aggressive patient relations department. We respond to complaints with plans of corrections in the patient’s best interest. We do both the humanity and the patient part, and it’s important that we properly stay in business.

Some people say, “You know, well, you guys, make money with what you’re doing.”

I said, “Well, if you don’t make money to pay Con Edison, which is the local vendor of electric… You know, if you can’t keep your lights on, you can’t treat people.

Now, our hospital… I’ll give you an idea of the magnitude of what we do. We saw, as an institution, 1.15 million clinic visits last year. Okay? And that is just a staggering number. We take care of… Now, some people will come more than once, of course, right? So we take care of that, represented, about 430,000 unique people. Okay?

Scott: In one year?

Ira: Per year. In one year.

Scott: Yeah.

Ira: Okay. 430,000 people, that’s larger than the city of Cleveland, Ohio. And I saw, I looked on the internet, and I looked and found on the Academy of Orthopedic’s site that there was 166 orthopedic surgeons listed for Cleveland, Ohio and its surrounding areas. And so, we do it with 14 providers, and they do it with 166. When I got here, the orthopedic department, like I said, was mainly a locum tenens type of thing. I mean, they were full-time but it was a revolving door. And it wasn’t a full department, it was a division. And they saw about 3,500 clinic visits a year and did about 200, 230 operations.

We now do 50,000 clinic visits a year and do about 2,300 operations a year.

Scott: That’s just remarkable. It just is remarkable. And for somebody who has known you for so long, and when you went there, I thought, “Wow, this is gonna be some heavy lifting.” And those numbers, you know, frankly, are remarkable.

So from a repeatability perspective, if this were to say, move to…I’ll pick my hometown. Down here in New Orleans, we do have a brand-new hospital system down here that did replace Charity post-Katrina, but let’s just… And it’s beautiful. It’s a great hospital.

That being said, I don’t know how many patients they take care of. I know the demographic is there for it, but there is a lot of people in need. Would they need all of that IT?

Ira: I think they need some type of business intelligence and clinical intelligence. It’s valuable to know how you’re doing, what’s working, what moves the needle of patient satisfaction, what moves the needle of the type of procedures you’re doing. But it really starts with leadership and a belief that you can build it organically. And I think that’s the big lesson. A lot of these hospitals, like, let’s say Hospital X, it’s in indigent area, goes to the big medical center, Medical Center Y. And Medical Center Y gets a contract to deliver orthopedic services there. So they send over some orthopedic surgeons in some type of schedule to cover…I’ll put that in quotes, “cover” the indigent hospital.

I just think that model does not work.

Scott: And it is the standard model. So if you are an orthopedic resident or you’re in orthopedics, this is the standard modality. You basically get into a program, and there’s the… This is the way I see it, and you tell me if I’m wrong. There’s the fancy private hospital. There’s the “poor” hospital, for lack of a better way to put it, but for indigent care. And then there’s the DA hospital that is somehow associated with this. There might be another one, but that’s the tri-factor, so to speak. Am I correct? Like, that’s the standard.

Ira: Yeah. I think that’s a good way to look at it. And instead of saying fancy private, I would say the university hospital or the major central hospital, the academic hospital.

Scott: That’s right. It’s not the fancy, but it could be that the fancy private is the fourth one. But yeah, you’re right. You need the one teaching hospital.

Ira: Yeah. Tertiary care center, but maybe also, a trauma center. But invariably, the hospitals that need to be vibrant community caregivers need to grow organically. Because you need people like, I believe, the doctors, and the allied health, and the health workers in the department, and the administrators are committed to the mission of the hospital in serving the people in this community.

Now, no one does it for free. But on the other hand, there’s a level of commitment to a community. You need people who are committed to their churches, that are committed to scouting, that are committed to sports programs, you could be committed to a community in the hospital.

In fact, our line for the hospital is, “doctor to the community.”

Scott: It’s an interesting point that you bring up because in the previous model, the way that it’s set up, it’s like, “Well, we’ll, kind of, swing by and try to help you, poor guys, out.”

Ira: Right. Or even if they mean well…

Scott: I think they do all mean…

Ira: They do have the idea of, “We’re gonna swing by and give you the minimum on this contract.”

Scott: There you go. That’s right.

Ira: And in reality, we truly have grown organically. And when you grow organically, you grow roots. And it’s harder to rip that out. You know, when I find this contract, a couple of city hospitals have some contracts, and one of them dropped one contract group and they added another contract group. That change just can’t be good for the community of patients.

Scott: I couldn’t agree more.

Ira: You know, every three to five years, a different cadre of orthopedic surgeons comes in. Now, we have turnover in our department, but we have normal turnover of some people. The focus of the department and how we run and how we deliver the care and the service is incredibly consistent.

We lost one of our top joint guys before we attracted another one from special surgery. And because the system works so processed and so mapped out, they guy who took over, actually, within the first six months, got busier than the guy before him and was more efficient because we learned more when the last guy was here.

Now, that was only 1 person out of 14 that we lost one year. Some years, I lose 2 out of 14. But it’s, sort of, they go into a system that’s already there.

Scott: We’re gonna have to kinda close this up. But I do think one of the takeaways from this is that you gotta be patient…some takeaways to me are the criticality of being patient-centric, the criticality to measure. And the systems that Ira has put into place are absolutely critical. And then the commitment. It is amazing to me that one orthopod, and I know the two orthopedic surgeons, the one that left to go to another place, which is still a friendly alum…

Ira: Right.

Scott: …that went somewhere else, and was very helpful when he left in helping onboard the other person. And the new person who came on board, for me, who don’t know better, it’s somebody who graduates at the top of their class, goes to one of the best residency programs in the United States for total joint replacement, and says, “No. I’m not gonna go to the fancy place. I’m not gonna go to private practice. I’m gonna go to the South Bronx, and I’m gonna go get started up immediately and take care of good people with complex problems.”

And I think the real win here for everybody is that not only are the patients are being taken care of, the surgeons are being trained very well, the community is getting taken care of. And I’m gonna repeat this over and over. Anybody who wants to learn a little bit more about how this is done, and how they could do this themselves, I know that Ira, Dr. Kirschenbaum, will be happy to connect with you and help in any way possible.

Ira, I really wanna thank you for taking the time to talk about how you did this. It’s remarkable. And I appreciate you carving out a half hour of your day for us.

Ira: It’s my pleasure. Thanks very much. You guys are doing great work.

Scott: Thank you.

Michael: “Paradigm Shift in Healthcare” is brought to you by P3 Inbound. You can find our full archive of episodes at paradigmshift.health. And recommend a guest or topic on Twitter, @p3Inbound.

Announcer: Thanks, again, for tuning in to the “Paradigm Shift of Healthcare.” This program is brought to you by P3 Inbound, marketing for ortho, spine, and neuro practices. Subscribe on iTunes, Google Play, or anywhere you listen to podcasts.