Understanding Palliative Care, Dr. Michael Fratkin Ep. 29

A Life & Death Conversation with Dr. Bob Uslander

Dr. Michael Fratkin founded ResolutionCare to insure capable and soulful care of everyone, everywhere as they approach the completion of life. Learn how telehealth applications are bringing a greater quality of living and dying to those in need.

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ResolutionCare website

Transcript

Note: A Life and Death Conversation is produced for the ear. The optimal experience will come from listening to it. We provide the transcript as a way to easily navigate to a particular section and for those who would like to follow along using the text. We strongly encourage you to listen to the audio which allows you to hear the full emotional impact of the show. A combination of speech recognition software and human transcribers generates transcripts which may contain errors. The corresponding audio should be checked before quoting in print.

Please note there is some content that is explicit in this episode.

Dr. Bob: Dr. Michael Fratkin is the President and Founder of Resolution Care. Dr. Fratkin is a father, a husband, a brother, a son, a physician, and a very dear friend of mine. Dr. Fratkin is dedicated to the well-being of his community and the community of all human beings. Since completing his training, he's made his home and built his family in rural Northern California. He's served his community as a primary care physician in the community health system, as a medical director of the local hospice, as a leader in the community hospital medical staff, and has been a transformative voice for improving the experience for people facing the end of life.

At a time of great demographic and cultural change in our society, Dr. Fratkin has created Resolution Care to ensure capable and soulful care of everyone, everywhere, as they approach the completion of their life. Resolution Care is leveraging partnerships with existing healthcare providers and payers to provide telehealth services that bring a greater quality of life and greater quality of dying. The palliative care team at Resolution Care openly shares their expertise and mentorship so that people can receive the care they need, where they live, and on their own terms.

In this podcast interview, Dr. Fratkin shares his passion and his intimate experience as a provider of care. He's innovative; he's creative, he's dedicated beyond what I've experienced with just about anybody else who I've communicated with about palliative care and end-of-life care. I think you're gonna find this podcast to be incredibly informative and really interesting.

Okay, Michael, thank you so much for taking time out of your day. I know you've got lots of irons in the fire and lots of people vying for your attention. So I really appreciate having time to connect with you.

Yeah. You know, it's interesting. I always enjoy talking with you. We connect sporadically, not as much as either of us would probably want, but we have been pretty consistent in finding times to connect and catch each other up on what's happening with our lives and our different enterprises. And what's interesting is, after our conversations, I always think to myself, "I wish other people could have heard that. I wish other people had a chance to listen in and hear what we're developing, and sort of the passion that comes out in these conversations." They're so informative, for me, and I find it so inspiring to hear what you're doing and the service that you're providing and creating. So today we have that opportunity so that people are going to be able to listen in on our conversation.

In the introduction, I shared a bit about what you're doing, who you are, but I'd like to have you just do a little synopsis of what Resolution Care is doing currently, where it started from its humble beginnings, and what your vision is for where this is heading.

Dr. Fratkin: I'm a dad, I'm a husband, I'm a brother, I'm a son, I'm a whole lot of stuff. But I'm also what's called a palliative care doctor. And your group of listeners probably know a little bit about what that is, but the way that I describe it for people is that there are really three central elements. That number one, we don't take care of any patients. We support people as they find their way through serious illness. We support people with a team; we support their families. Our team includes nurses, doctors, social workers, chaplains, nurse practitioners, community health workers, and all the people that they don't necessarily see, but that are just as important to creating a container for our care, the back office, and operational people.

So the first principle is, is that we are a person-centered, not a patient-centered, but a person-centered initiative. And that those persons, the reason I distinguish it ... It's not just the patients or their families, but the people providing the care that are centrally important to everything that we do. And then we build out from there.

So the first thing is, we're a person-centered organization, using a team to accompany people with serious illness as they navigate it, right?

Dr. Bob: I love it.

Dr. Fratkin: So the second thing that we do is that we're really damn good at managing symptoms. Our team has quite a bag of tricks around the treatment of pain and nausea, breathlessness, and various other physical manifestations of illness. And we know how to use that bag of tricks. So symptom control is the second thing. And the third thing is, we help people and their families to navigate what is a completely dysfunctional, fucked up if you don't mind me saying so-

Dr. Bob: Let's call that like it is.

Dr. Fratkin: Of fragments and silos and conflicting interests, and stakes held. We help people navigate, somewhat, through the complications of their illness, but more so, we recognize that people are trying to make their way through a human experience, not a medical one. And so, we help them navigate through that, bringing the personhood that we are to accompany them with the wisdom, skills, and shortcuts and strategies that we know about navigating. So it's person-centered around the people we care for and us as well. We matter, too.

It's impeccable symptom control, and it's navigational assistance. And really tough times of life in a really complicated health care system. So Resolution Care does that. And we use some technology tricks, video conferencing, all of our care is based in the home. And that's that. But I think I also wanna tell you about how I got here and why.

Dr. Bob: Please do.

Dr. Fratkin: So I came to far Northern California, Humboldt County, in 1996 and joined a community clinic environment as the only internist in a five-clinic system. And my job was to take on all the patient V patients and all the complicated conditions that provided kind of complex case management approach for the heavy hitters, the outliers, the hot spotters. They're called lots of things now, but they were just languishing without the attention they needed when I showed up in town. And for six years, I took the hardest cases in the system, and helped with diagnosis and treatment planning, and burned out rather quickly, because I didn't have a team.

I then sort of shifted my attention to my deep connection with hospice work and became a hospice medical director, where I did have a team. But I also had a very constraining box around me, a structure of hospice defined by the Medicare benefit that was limiting our ability to do what made sense, rather than meeting all of the regulation and compliance that continues to accumulate in the hospice model of care. And I burned out again. And then, I did some hospital work. When I started, I was seeing 9-12 people in a day, and I really enjoyed being at the point of the sphere where people were sick enough to be hospitalized and to attend to them both with good medicine, as well as a respect, and frankly, love in the face of what they're going through.

And that was great until they started to push me to see 15 or 18. And now, it's 22 patients in a 12-hour shift. And I burned out again. And all the while, paying attention to the rising credibility and relevance of the palliative care movement. So I became first certificated in 2000, and board-certified a few years after that, in palliative care. In 2007, I worked with the hospital to launch a guided care consultation service in the hospital. And as soon as I got started doing that, there was almost immediately, four or five times as many people as I could care for.

And I wasn't able to scare up the resources in the hospital to build out a team. So for a period of years, I wrote business plans, I went to committee meetings, I tried to advocate for greater resources to do this good work correctly, and failed to do that. So in 2014, I had had it. Exasperated, fatigued, burned out, I guess for the fourth or fifth time. God knows I can't keep track. I was looking for a job. I figured I couldn't stay here in this beautiful community, because I couldn't figure out how to get a sustainable job with a team that builds capacity over time.

And so, I looked for work. And as you know, Bob, a palliative care doctor these days doesn't have to go too far to get too many interviews. I had three interviews in three weeks in the Bay area, and on the way to the Bay area. And they offered me three jobs, quickly, were better resourced, better compensated, more controlled work hours, but none of them were where I lived, where I made my home, where my kids were born in my house. I live on this five-acre piece of redwood forest. My kids were born there. My dogs and cats are buried in the yard.

And I didn't wanna leave. So come around spring of 2014, I started to think about maybe there's a way to build capacity, build a team, and share what I know to others so that they could make that work for the people they're caring for. And so, the three ideas were video conferencing, Project Echo, which we could talk about later, it's a telementoring structure that allows a specialist to share information to primary care providers, et cetera. We can talk about that later if you want. And then the third thing was crowdfunding.

So in November 1st or 2nd in 2014, we launched an Indiegogo campaign and based on all of my relationships in the community and people's trust in my work, we were able to raise $140,000 in a little over a month. And in January 2015, myself and one other person walked into a donated office space and turned on the lights.

Dr. Bob: What a great story, and a great confluence of ... And you being true to your vision, being true to yourself, to what you knew was the absolute right way to practice the ... And you took a risk, right? And you continue every day, taking a risk. I know it. We've had these conversations. I'm trying to remember when we first connected because I've watched this thing go from birth to flourishing. And flourishing may not mean the same thing to you that it does to me, because I know your vision is grander.

Dr. Fratkin: Well I know where we met. We met around ... There's a group in San Diego of one old-timer, one mid-timer, but some folks that have been inspired for more comprehensive cancer care in the community for a long time. A fellow by the name of Dan Vicario and the dear, dear friend of mine. I call him my grand brother, Paul Brenner, a psychologist with a deep connection. A psychologist and physician with deep connections to really thoughtful and complete approach to people with serious illness.

And it was through them that they connected me to you.

Dr. Bob: Right. And I remember that part very clearly. And I've had the honor and the privilege of collaborating on patients with both of them. And it is really; it's magical to be part of that with all of their combined years of wisdom and their just beautiful energy. But I'm trying to remember the stage that you were at. It was probably early on, and-

Dr. Fratkin: It was probably in 2015. And without getting too wonkish about enterprise development so that we can get to the topic at hand, 2015 was the year of getting rolling and getting the team. And we did that. By September, we had a nurse, a social worker, chaplain, and office staff, as well as a little bit of a head of steam, with a group of patients. 2016, we really started to grow. And 2017, we continued to grow and sort of learned how to be a business that was sustainable. And coming into 2018, I'll just tell you today, Resolution Care network is tending to about 164 people in their homes, from the Oregon border to the north, the Pacific Ocean to the west, all the way to the ... I guess it's the Idaho/Nevada border to the east, south, pretty much to the Bay area with a couple of other folks a little bit further south.

We've got 29 employees. We have contracts with four health plans. And we're making an impact with this model of care that we're developing. Yeah.

Dr. Bob: That's beautiful. And of those 164 current patients, how many of those are receiving physical ... Are you able to get to visit physically, versus doing it entirely through video conferencing?

Dr. Fratkin: It's variable. The key element is, is we really do what makes sense. So if a person lives down the street, it makes sense just to drop in and see them and sit on their couch and eat their cookies and chat with them that way. If they live 150 miles away from HQ, we're much more likely to engage with them by video conference. And it's really ... That's kind of what we built into the model. It's a hybrid model, both boots-on-the-ground, face-to-face encounters, with teleconferencing or video conferencing.

And we do that in a really nimble fashion so that there are some people who really can't wrap their head around it. And if they're close enough, we provide them with a more traditional home care model. We have people who are right down the street who are very comfortable, in fact, prefer not having somebody knock on the door and walk into their house, but prefer to control the framework of the encounter. And then, different specialties. For my fellow providers and me, we're probably in the 85-90% video conferencing channel. Our nurses are probably in the 50-60% of their direct encounters are done by video. Our community health workers, the other end of the polarity, do very little video conferencing, because that's kind of what their value proposition is, is to be right there in the home with time and engagement to suss out what's needed.

Our community health workers extend the reach of our doctors, our nurses, our social workers, and our chaplains. And they're given a lot of room to figure out what makes sense for each person and their family. So it's a variable ratio of boots-on-the-ground to remote engagement.

Dr. Bob: Right. And what's cool about it is each situation is unique, and it probably changes over time as well. And I think it's fascinating; the different disciplines have the option of doing it whichever way makes the most sense for the provider as well as for the patient and family.

Dr. Fratkin: For sure. At an organizational level for organization people who might be listening, it makes such great sense to use the technologies to eliminate the inefficiencies of travel. What's interesting ... I think we've talked about this before, but when I started to do initial consultations with people, first encounters to carry the arc of ... Oh, there are 8 or 10 elements that I've gotten accustomed to, to feel complete within an initial encounter. When I did it in a clinic setting, or at home, it was a 90 to 120-minute encounter, easily, and really exhausting.

But when I started doing those same initial encounters by video conferencing, over and over and over again, they came to a place of completion in about half the time.

Dr. Bob: Why is that?

Dr. Fratkin: I think it's because we are primates. I think that when you walk into a person's home, there's a whole lot of social primate behavior. There's a whole lot of framing that includes so much more than just the relational engagement, one-on-one, with another person. There's the environment; there's the space, there's how the person feels about inviting a person into their home. There's their level of attention to, let's say, housekeeping, or their level of anxiety about how much energy they have to do housekeeping. There are the dogs; there's the feeling like you're hosting a doctor in your home, or a social worker, whoever.

There are the elements of ... If you're really, really sick, maybe you just didn't feel like taking a shower this morning, but the doctor's coming, so you have to put yourself through a whole preparation mode. All of those things are, frankly, in the way of a relationship of trust. They're complications. So I've come to accept that actually doing care virtually is better than real life.

Dr. Bob: Fascinating. I find that fascinating, because I do some care, some visits remotely that way. The vast majority, 95+% of them are in patient's homes. So those social, primal, primate behaviors, to me, I find those really endearing. And I think it's almost like a friendship is developing at the same time as a doctor-patient relationship. But I'm not seeing the same volume as you, so I have the luxury of being able to do that at this stage of the game.

Dr. Fratkin: I think that's true. I think there are some other things that are hidden in plain sight that relate to it. I'm sure you'll agree that one of the great challenges for hospice work, palliative care work, complex conditions, where people with huge loads of social challenges with sensitive, inspired, caring caregivers and healthcare professionals ... One of the greatest challenges to this work is learning about the nature of boundaries. It shows up in every hospice organization, every palliative care organization, in the hospital, where people get confused about where they begin and where the people that they're attending to begin, or where they begin and end.

The I and Thou, to quote Martin Buber. That is very interesting and hard to teach. The way that most of us learn is that we screw it up. We get caught up with the other person's energies. We end up feeling we must keep them pleased. We don't necessarily ... Well, here's the teaching metaphor that I use. I'll see if I can create a visual of this for you and the listeners. Bob, do you remember way back when, in the dark ages, when you took Physics?

Dr. Bob: Yes, vaguely.

Dr. Fratkin: Vaguely. And do you remember studying the components of an electronic circuit?

Dr. Bob: Even more vaguely.

Dr. Fratkin: Okay. Things like resistors and transistors.

Dr. Bob: Capacitors.

Dr. Fratkin: Capacitors and stuff, right? Now, I bet you don't quite remember. Maybe you do. You're a smart guy. What a capacitor actually is. Do you remember what a capacitor is?

Dr. Bob: In the interest of time, I'm gonna let you-

Dr. Fratkin: That's good. Good call, Doc. A capacitor is this: it's two plates. Imagine tiny little squares. One of them's a positive, anode; the other is the cathode. I think that's right, a negative. And they sit inside of a circuit with a proximity to each other and a surface area. And the closer they are together, and the more surface area they have in association with each other, the higher the capacitance. Whatever the stuff of capacitance is that contributes to doing what's needed to an electronic circuit, which is way above my pay grade, is proportional to the surface area and the proximity.

And I think that that's better than thinking about staying professionally or technically detached from the people we care for. What we've built is a system that constructs ... All I'm here to do is to give you the technically, medically best treatment. And I can't really allow myself to engage with the truth of what's going on for you as a human being, because that'll make my hands shake in the operating room. That'll make me not make the right choices on your behalf, or provide you with the right recommendations.

And I think what that done is it's alienated healthcare professionals from the people that have medical challenges, right?

Dr. Bob: Absolutely.

Dr. Fratkin: Professional detachment is a 20th century, obsolete concept. My concept is that what we're called to do, especially for people who are feeling the threat to their very existence, is to open as much of ourselves as we can, create a greater surface area, and have the courage to maintain the closest proximity to their circumstances. To understand what's going on. But what happens with the capacitor ... If the two plates touch-

Dr. Bob: Kaboom.

Dr. Fratkin: Circuit's completed, and there's no capacitance. If you get caught up in people's shit, then you lose the ability to really create the magic that lives between those two plates in close proximity. In human encounters, I say that it's not capacitance that arises with proximity and willingness to be open. What arises is empathy. And empathy is the secret sauce of understanding how to be of service to another person. But if you're caught up in them, if their happiness or well-being becomes relevant to your own happiness or well-being, then you've completed the circuit, and you lose the capacity to have the perspective of being of service to them. It's a long and involved metaphor.

Dr. Bob: Yeah, but it's a great one. It's a great one. I'm gonna-

Dr. Fratkin: Here's an example. With your wife ... Or actually, with my wife, being with my wife, not you with my wife, but me with my wife ... We are intertwangled. And we sometimes struggle to have enough individuation to understand what each other needs. But we're necessarily, intimately one. One circuit, my family, right? And so I struggle with different kinds of things there than I do in work. It's not a matter of distance; it's a matter of entanglement.

When I, for example, being asked to see a 56-year-old person with a brain tumor and two children, the distance I can get in proximity to him is greater than with an old woman who doesn't look anything like my own life. So I have a little bit more room. Others on my team may be able to step right into tending to that father. But for me, I have to create a little bit less proximity in order to make sure that I don't get entangled in the reality of what's going on for him because it so resonates with my own fears and worries about myself.

So I can manage the proximity consciously, and by having a team that has a whole different set of concerns and triggers. There, we're intentionally talking about the distance we can tolerate. The best possible scenario is you're almost touching, but not quite. So we have to manage that consciously, and that is one of the ways that I train people around boundaries. This is a very circular way to talk about what I think one of the great advantages of video conferencing in a frame, is that it's literally a frame around the encounter, around the relationship and development.

It's necessarily a division. It's necessarily a boundary. And while I can get very close and understand empathically what that person is having, I'm not sitting on their bed. I'm not reacting to their place on the political spectrum, which may be revealed by their red baseball caps or bookshelf. I'm not struggling with my own biases. They are in their most comfortable place as a person, not having had to prepare, go to a clinic, and deal with the waiting room and all the rest of it. They're just at home, as themselves.

And I am similarly in a work environment that I've constructed, that I'm very comfortable with. And so, in some ways, the frame around which we ... within which we encounter and develop a relationship, has this necessarily built-in boundary. And so I think that's part of why, rather than two hours, it takes one hour to get to the same place. And that once people have the experience, it's much, much more comfortable for them than home invasions.

Dr. Bob: Fascinating. What's interesting is, I'm assuming ... Correct me if I'm wrong, but I'm assuming that this has all just been learned as you built this. The rationale and the initial inspiration for doing video conferencing, I'm assuming, was efficiency and being able to connect with people who are in more remote areas. I'm sure that you had very little awareness or understanding about all these additional benefits and advantages that you've come to, that you're just describing.

Dr. Fratkin: Yeah. Well, just like I don't have any idea what benefits and nuances and subtleties I'm yet to discover over the next few years. But yeah, you're right. I mean, I started because I noticed that I have had this amazing smartphone and that I'm using it to text and to call and to talk to people on the phone and all the rest. But I realized that it was worth exploring, whether or not a synchronous audiovisual experience with two people in two different places, working on the same thing together, whether that would work. Because I have this crazy, amazing supercomputer in my pocket called an iPhone.

So a lot of it was curiosity. I didn't really quite get the efficiencies and the network development until I started playing around with it. The way that I discovered it was, a friend of mine who works at Google told me about a project that came and went over about 11 months, called "Helpouts." And Google had this project where they were setting up a platform that included video conferencing, the "Hangouts" app, a webpage that you could tell your story about what expertise you wanted to share with other people, a scheduling function, a wallet function, and a messaging function, all on one little webpage.

And if you had Chinese cooking that you wanted to teach, you could put your page up there, invite people to take a look, and if they wanted to schedule you, they could. And you'd charge them $15 for a half hour or whatever you wanted to charge. If you wanted to help people with their business plans or filling out their tax forms or whatever other expertise you might wanna share, you were out on the sort of open market, and direct consumer engagement would allow you to do it.

So he asked me, would I wanna do it for palliative care. And I said, "Yeah, sure." So I spent two hours throwing up a little thing, and within a month, I had five people reach out to me. And the first person that did was a woman who was in a hospital in the Bronx, in terrible pain, from a metastatic cancer problem. And she was miserable and interested in talking. So we connected, and about five minutes, five seconds, the technology itself disappeared, and there I was, doing my thing.

And within 30 or 40 minutes, we're both kind of in tears about the big picture of things. And it was really clear that some basic fundamentals of managing her symptoms would make a big difference. So I got her permission to reach out to the hospitalist tending to her. He was willing to talk to me. I told him, "Do x, y, and z." And the following day, she was discharged from the hospital. And I connected again, and she was so grateful for that advocacy and the difference that it made in her life. And I knew that this could so work.

Dr. Bob: Yeah. What a beautiful story to spearhead and show you the impact.

Dr. Fratkin: So it was more about just curiosity of what can I do with this crazy iPhone in my pocket? I hadn't really put it together that I was gonna build a social enterprise called Resolution Care at that point. I was just trying to figure out why are we not using this tool? And so I started using it, and it worked.

Dr. Bob: That's great. So hey, I have a question. You and I, we're both palliative care physicians. We both specialize and are passionate about bringing people the best possible and holistic support to deal with their struggles and their challenges. And we know what works, right? And anyone who's involved in palliative care understands the value, sees the value on so many levels. On the human level, the financial level, the social level. Why are we having ... Why do you think we're having such a hard time getting traction and seeing palliative care become what it needs to become? Because you're working within the system. You're working with insurers, and you're working with the whole Medicare and insurance billing component, as well as contracting.

What's your take on it? What's going on? I know it's a big question. And it's not a simple answer, but I really wanna hear your thoughts on it.

Dr. Fratkin: Yeah, no. I think I would probably disagree with you. And only because-

Dr. Bob: That's good. I'm happy to hear that, too.

Dr. Fratkin: Only because this morning I happened to have a little bit of perspective. I don't know why that is. It might be just; I hit the number of cups of coffee just right. But I think what I would say is it's happening at an almost spectacular pace. It's amazing what's occurred for our society as it relates to our mortality in the last few years. That there's a transformative change in the public conversation around death and dying. I just happen to be pretty well-timed to get up on my surfboard and ride that wave, while also contributing to that wave through having conversations like this one.

But let's go back to 2014. In 2014 in October, the Institute of Medicines Dying in America study, the second version was published. It was, I think, 10 or 11 years after they did it the first time, where they did a very deep dive into how people in America finished their lives. And what they basically said in that report was it sucks, and it hasn't changed in 12 years. It talked about how much bias there was and how little capacity there was for palliative care in cancer patients. But they also talked about the aging population, the demographic shifts that are intensifying this sort of tsunami, silver tsunami of people with a greater burden of illness, and the cost of health care, and the absence of focused and targeted support structures for people as they completed their life.

And they said, "Why hasn't it changed for 12 years?" A month later, Atul Gawande published "Being Mortal," a blowout success that surprised even him, about bringing this conversation to "How do we die in America?" To a more narrative discussion. And you and I, in our field, we've been talking about these issues for 20 years, maybe longer. And I ask myself ... Well, actually, when Atul Gawande presented to the American Economy of Hospice and Palliative Medicine in 2015, he was interviewed by the Philadelphia Inquirer. And before his presentation, he says, "Gosh, Dr. Gawande, you have this blowout New York Times bestseller. Everybody's reading your book. What are you gonna tell all these hospice and palliative care doctors when you talk to them tomorrow?"

And he said, "Well, I'm gonna say thank you. And I'm gonna ask the question, 'Why haven't they been listening to you?" And I was disappointed the next day when he actually didn't ask that question. He [inaudible 00:40:34] from his prepared remarks. But I found myself, for the next few days, thinking about that question [inaudible 00:40:42]. Why haven't they been listening to those of us that have been doing hospice or working with death and dying, working with families very closely, learning what brings value to them? Why haven't they been listening to us?

And I think the answer is that we were talking to ourselves, talking to each other, thinking in terms of big health care delivery systems and academic papers and elevating our own careers through the accumulation of initials and prestige and all the rest. The academy of hospice and palliative medicine was academic, an ivory tower, and not really directing its attention outward. And I told Gawande, his voice was completely outward-directed, and it wasn't because he was such a great doctor. It was because he was a son. And being mortal, he's a clueless ears, nose, and throat surgeon who was getting it wrong. Then he, as a son, experienced the challenges that his father faced. And that transformed his perspective as a physician.

So his story of conversion was related not to his role as world-famous, world-renowned surgeon. It was related to his role as a son. And so he ... And he's such a brilliant communicator and journalist. Now fast-forward three years later. He is selected by Berkshire Hathaway, Amazon, and whoever the heck, to lead an organization as a symbol of what's possible by thinking out of the box. And as a symbol, that his orientation is grounded, his career has exploded so that he is the leading, most exciting CEO in health care. And he's completely grounded in an understanding of what person-centered care must turn out to be.

Dr. Bob: Yeah. That is exciting. That's an exciting development.

Dr. Fratkin: And then there's BJ Miller and the traction that he got telling his story as a TED Talk. And then there's Jessica Zitter with her book, called "Extreme Measures." And then there's Shoshana Ungerleider, working in the Bay area, kind of behind-the-scenes, producing powerful documentary films, one of which, "Extremis," was nominated for an Academy Award. But these powerful experiences taking the public into places that we've been populating for decades. The intensive care unit, or the hospital-based palliative care program.

And bringing people into that, that wouldn't otherwise look. Not to mention, the millennial spirit of younger people is that they don't blink. They don't avert their gaze at what's difficult. They tend to be drawn towards things that represented shadows for the previous generations. So I think there's a lot happening, that's happening very fast. And in three-and-a-half years, we built this organization kind of on the strength of that, and with the advantage of being an outsider like you, Bob.

Dr. Bob: Well, I appreciate that perspective. And hearing you speak, it's inspiring. And it's true. Things are happening. There is a groundswell. I guess my perspective, A) I'm just, in general, a very impatient person. And B) I'm out here in the community speaking. And my of the talks are really focused on older groups, and I still have rooms that are filled with people who just don't really know about palliative care. And when there is palliative care in the community outpatient setting discussed, a lot of times, people have felt that it couldn't fulfill their needs. Because there's A) not enough providers, B) the offerings are not complete enough. And a lot of that has to do with the payment, the reimbursement models.

So on the one hand, I do see that we are moving in the right direction, and that's exciting. And at the same time, I'm frustrated because I still ... And as I know, you see this as well. We still see people who are day-in and day-out, struggling, because their needs are not getting met. And we know what they need, and it's just not available to enough people today.

Dr. Fratkin: No. It's super true, Bob. I mean, I feel exactly the same way. And for my own psychic well-being, there was a long time ago that I had to make the choice that I wasn't gonna focus on the unmet need or demand as the target of my attention. I was gonna focus on building capacity. And that I was gonna not worry about the fact that I could have burned myself out again trying to deal with one out of four people that I could get to in the hospital. I could have stayed inside of that, like most of us do, just trying to push that boulder up the hill. But what I had to do was to take a risk and say, "For those three or four people I don't get to, in their interest, not the same people but the next three or four or five or six or 12 or 250, it's gonna take some strategic thinking to build capacity."

And there are so many sad stories. And as soon as I hear their names or hear some element of their stories, my heart starts to break and be frustrated with them that they don't get the service or don't know that there's a service that would help them. But my focus is not so much on those people; as it is, I know there are so many of them out there that my best efforts are to build capacity to manage and to set the tone of what palliative care capacity building looks like.

We believe that it's not just whatever you could cobble together with crappy resources from whoever your institutional home is. Palliative care is best provided by a team of individuals who are well-supported in sustainable, soulful workplaces, but include a nursing perspective, a chaplaincy perspective, a social work perspective, and provider perspective. We are committed to that. So what we provide is actually pretty expensive. And the good news is, is that what we provide delivers to our health plan partners, a three to five x return on investment. Every dollar they spend turns into three to five that they saved.

And they can measure those dollars. So they're interested in program development and building capacity for us. We think in the state of California, less than .5% of people who would benefit from palliative care support are getting it. If I focus on that 99.5 % of people who are suffering terribly-

Dr. Bob: You'll be paralyzed, right?

Dr. Fratkin: It breaks me down.

Dr. Bob: Yeah.

Dr. Fratkin: But I'm trying to get from .5 to 1. And I'm trying to do it by providing soulful, sustainable, meaningful experiences for my treasured colleagues. Nurses and all these people who, 100 years ago or 500 years ago or 5,000 years ago, would still be doing the same thing. They wouldn't be called nurses; they would be called neighbors. They would be called aunties. They would be called "the ones you call for help when you need it." It's been a part of human society forever, and we are burning out those people in a terrible way.

So I'm just as loyal to creating incredible work experiences for those folks, as I am to building capacity to tend to the needs of sick folks, too.

Dr. Bob: Yeah. And that's a beautiful thing. And that's how this will grow, sustain itself, by nurturing those who are serving others. Because this work, it's difficult, it's challenging, it is emotionally trying, and as I think we both experienced this, it is such ... It also fills us up in a way that nothing else does. And we don't throw the word "love" around enough. We had a meeting with my team a couple days ago. And when you try to really identify the essence of what we do, and really what we do is we love people, and then we take our skills and our experience and our wisdom, and we apply those in the way that we express our love for them.

Dr. Fratkin: For sure. I was talking to a Native American fellow who lives up in the hills. And I was exploring with him his relationship to tribe and culture. And I'm not sure how we got there, and I wish I could remember the pronunciation of the word, but I won't massacre it. But he was explaining to me that there's a word that's being used by the tribe and others that kind of means "thank you," but it's being used in the "thank you" way. In a very, sort of, superficial way. But he said that the word itself is very much more specific.

It's the kind of thank you or gratitude that's offered to someone who showed up to meet a need you had. If you're old and someone brings you food, it's the thank you for that. If your roof is leaking, but you can't fix it or afford it, and the guys hop in the truck and start throwing shingles on your roof, it's the thank you for that. It's the thank you for showing up and meeting a need for someone in your community. It's not "Thanks." It's deeper than that. And the presence that we bring, the willingness to love while preserving boundary, the willingness to respect the otherness of these people that we care for.

And the willingness to drink a lot of coffee and build out a system to create beautiful jobs and keep the vision as clean and clear as possible. It's the thank you I feel from the community, even if I don't hear it said. I'm so proud of what this team has done for so many people we've touched. 1100, 1200 people who wouldn't otherwise have gotten this care. And that means there are 5-10,000 people who we didn't touch. I'm sad about that, but I'm proud of the work that this incredible team has done over these last three years with very little resource and a ton of coffee.

Dr. Bob: Yeah. And a ton of passion and a ton of-

Dr. Fratkin: Love.

Dr. Bob: Love and determination. And proud you should be, my friend. And I'm excited to continue to follow your progress and the progress of Resolution Care and the impact that you're having. And your model is a model that I'm sure many will want to learn and try to apply in their communities. So before we sign off, I would love for the listeners to go and check out your website. That's resolutioncare.com. And in addition, there's a foundation and an opportunity to help support this amazing, so, so needed care.

So you have a 501C3, I understand.

Dr. Fratkin: It's called Resolution Care Institute, and there's a page on our website. And if people have a few dollars, they wanna donate, that's absolutely welcome. Yeah. And also, I guess I would ask them, too ... We create maybe once or twice a month what I consider to be pretty high-valued content in a newsletter. And I would love to build the community, so on the website, all you have to do is put in your name and email address, and we'll send you stuff. And if you don't think it has value, you just unsubscribe to it.

But I suspect you'll enjoy being a part of our community. We tend to ... We're trying to figure out how to tell stories about the impact of the work that we're doing while getting ourselves out of the way. Just letting people tell their own stories. So we've done that with some videos, and we've done that with some blog posts and other newsletters. And the response we get is favorable. So I'd really like to build that community out if people are inclined.

Dr. Bob: Yeah. Awesome. Well, we'll fully try to support that, and to everyone's benefit. And we'll also have the links for Michael's site and the ways to connect with him on our website, integratedmdcare.com. Michael, thank you. You're so passionate, articulate. I could listen to you all day, describing your views and your excitement about what you're doing. And I would love to try to connect again. And I know that there are several things that we wanted to touch on that we didn't have time to, but hopefully-

Dr. Fratkin: I'm happy to do this anytime, Bob. This is how we're making an impact, is by telling the truth and sharing that.